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HANDBOOK 

OF 

MEDICAL  Treatment 


EDITED    BY 


JOHN  C.  Da  COSTA,  Jr.,  M.D. 

Associate  Professor  of  Medicine,  Jefferson  Medical  College 
Philadelphia 


WITH    THE    ACTIVE    CO-OPERATION 
of 

FOURTEEN    ASSOCIATE    EDITORS 


IN      TWO      VOLUMES 

VOLUME  TWO 
I L L U  ST  R  A  TED 

WITH    AN    INTRODUCTION 

BY 

WILLIAM  W.  KEEN,  M.D.,  LL.D.,  Hon.  F.A.C.S. 

Emeritus  Professor  of  Sdrgeey.  Jefferson  Medical 
College,  Philadelphia 

SECOND     EDITION 


PHILADELPHIA 
F.  A.  DAVIS  COMPANY,  Publishers 
1920 


COPYRIGHT,  1919 

COPYRIGHT.    1920 

BY 

F.  A.   DAVIS   COMPANY 

Copyright,  Great  Britain.     All  Rights  Reserved 


3U 


I/.    2- 


PRESS   OF 

F.    A.    DAVIS    COMPANY 

PHILADELPHIA.  U.S.A. 


ASSOCIATE  EDITORS. 


FRANK  A.  CRAIG,  M.D., 

Instructor  in  Medicine,  University  of  Pennsylvania;  Visiting  Physician,  Henry 
Phipps  Institute,  University  of  Pennsylvania;  Visiting  Physician,  White  Haven 
Sanatorium;  Physician  in  Charge  of  the  Tuberculosis  Class,  Presbyterian  Hospital. 


JUDSON  DALAND,  M.D.,- 

Professor  of  Clinical  Medicine,   Graduate  School  of  Medicine,  University  of 
Pennsylvania. 


FRANCIS  X.  DERCUM,  A.M.,  M.D.,  Ph.D., 

Professor  of  Nervous  and  Mental  Diseases,  Jefferson  Medical  College,  Philadelphia; 
Ex-President  of  the  American  Neurological  Association;  Foreign  Corresponding 
Member  of  the  Neurological  Society  of  Paris;  Corresponding  Member  of  the  Neu- 
rological and  Psychiatric  Society  of  Vienna;  Member  of  the  Royal  Medical  Society 
of  Budapest;   Consulting  Neurologist  to  the  Philadelphia  General  Hospital,   etc. 


CLIFFORD  B.  FARR,  A.M.,  M.D., 

Associate  in  Medicine,  University  of  Pennsylvania;  Assistant  Visiting  Physician, 
Philadelphia  General  Hospital;  Professor  of  Diseases  of  the  Stomach  and  Intes- 
tines, Philadelphia  Polyclinic;  Formerly  Pathologist,  Presbyterian  Hospital,  Phil- 
adelphia. 


M.  HOWARD  FUSSELL,  M.D., 

Professor  of  Applied  Therapeutics,  University  of  Pennsylvania;  Physiciaru  to  the 
University  Hospital,  the  Episcopal,  St.  Timothy's,  and  St.  Mary's  Hospitals, 
Philadelphia. 


VICTOR  G.  REISER,  M.D.,  D.Sc, 

Director  for  the  East,  International  Health  Board,  Rockefeller  Foundation ;  For- 
merly Director  of  Health  for  the  Philippine  Islands,  and  Professor  of  Hygiene 
and  Sanitation,  College  of  Medicine  and  Surgery,  University  of  the  Philippines. 


J.  NORMAN  HENRY,  M.D. 


Visiting  Physician,  Pennsylvania  Hospital;  Formerly  Clinical  Professor  of  Medicine, 
Woman's  Medical  College  of  Pennsylvania;  Formerly  Assistant  Physician,  Phil- 
adelphia Hospital. 


(iii) 


iv  ASSOCIATE   EDITORS. 


WILMER    KRUSEX,    M.D.,    LL.D.,    F.A.C.S., 

Professor  of  Gynecologj',  Temple  University  of  Philadelphia,  Department  of  Medi- 
cine; Chief  Gynecologist,  Samaritan  Hospital;  Gynecologist,  Garretson  Hospital; 
Director,  Department  of  Public  Health  and  Charities,  Philadelphia. 


B.  B.  VIXCEXT  LYON,  A.B.,  M.D., 

Chief  of   Clinic,    Gastro-enterological    Department,    Jefferson   Hospital;    Pathologist, 
Methodist  Episcopal  Hospital,  Philadelphia. 


HEXRY  K.  MOHLER,  M.D., 

Medical  Director,  Jefferson  Hospital,  Philadelphia. 

RALPH  PEMBERTOX.  M.S..  ALD., 

Physician  to  the  Presbyterian  Hospital,  Philadelphia. 

CHARLES  E.  de  M.  SAJOUS.  MD.,  LL.D.,  Sc.D., 

Fellow  of  the  College  of  Physicians  and  of  the  American  Philosophical  Society: 
Professor  of  Therapeutics,  Temple  University  of  Philadelphia,  Department  of 
Medicine. 

S.  CALVIN  SMITH,  Sc.M..  AI.D., 

Instructor  in  Medicine,  Jefferson  Medical  College;  Acting  Chief  Clinical  Assistant, 
Medical  Clinic,  Jefferson  Hospital,  Philadelphia. 

SAMUEL  S.  WOODY.  M.D.. 

Chief  Resident  Physician,  Philadelphia  Hospital  for  Contagious  Diseases. 


CONTENTS 

VOLUME   II. 


PAGE 

Diseases  of  the  Blood, 3 

By  John  C.  Da  Costa,  Jr.,  M.D. 

Symptomatic  Secondary  Anemia,  4;  Chlorosis,  8;  Pernicious  Anemia,  17; 
Leukemia,  29;  Chloroma,  43;  Hodgkin's  Disease,  44;  Splenic  A-nemia,  47; 
Infantile  Splenic  Anemia,  50;  Purpura,  52;  Hemophilia,  56;  Erythemia,  CI. 

Diseases  of  the  Ductless  Glands,     .       .        .       dy 

By  Charles  E.  be  M.  Sajous,  M.D.,  LL.D.,  Sc.D.,  and 
Louis  T.  de  M.  Sajous,  B.S.,  M.D. 

Diseases  of  the  Adrenal  Glands,  67;  Adrenal  Insufficiency  (Hypoadrenia), 
72;  Adrenal  Overactivity  (Hyperadrenia),  84;  Adrenal  Hematoma,  87; 
•  Hypernephroma,  88;  Tumors  of  the  Adrenal  Bodies,  90.  Diseases  of  the 
Thyroid  Gland,  92;  Thyroid  Insufficiency  (Hypothyroidia),  98;  Infantile 
Myxedema  (Cretinism),  103;  Myxedematous  Infantilism,  106;  Thyroiditis, 
107;  Thyroid  Overactivity  (Hyperthyroidia)  and  Exophthalmic  Goiter, 
109;  Goiter,  118.  Diseases  of  the  Parathyroids,  126;  Parathyroid  Insuffi- 
ciency (Hypoparathyroidia),  129.  Diseases  of  the  Thymus,  133;  Thymus 
Insufficiency  (Hypothymia),  135;  Hyperplasia  of  the  Thymus,  141.  Dis- 
eases of  the  Pituitary  Body,  145;  Pituitary  Overactivity  (Hyperpituit- 
aria),  149.  Diseases  of  the  Pineal  Gland,  168;  Pineal  Tumors,  171;  Pineal 
Insufficiency  and  Mental  Retardation,  172.  Endocrinic  Disorders  of  the 
Ovaries,  173;  Endocrinic  Ovarian  Insufficiency,  177;  Endocrinic  Ovarian 
Overactivity,  182;  Elndocrinic  Disorders  of  the  Testicles,  184;  Endocrinic 
Testicular  Insufficiency,  186;  Endocrinic  Testicular  Overactivity,  190. 

Diseases  of  the  Cardiovascular  System,         .     201 

By  J.  Norman  Henry,  M.D.,  and 
S,  Calvin  Smith,  Sc.M.,  M.D. 

Cardiac  Irregularities,  201;  Pericarditis,  222;  Myocarditis,  228;  Endocar- 
ditis, 236;  Valvular  Disease,  242;  Angina  Pectoris,  255;  Aneurj'sm,  259; 
Arteriosclerosis,  267;  Blood-pressure,  273;  The  Use  of  Cardiac  Drugs, 
278;  The  Nauheim  Baths,  286;  Methods  of  Balneologic  Treatment,  287: 
Exercises  in  Chronic  Heart  Disease,  292;  Gymaastic  Poses  for  Resist- 
ance Exercises,  298. 

(V) 


vi  CONTENTS. 

PAGE 

Diseases  of  the  Respiratory  System,      .        .     325 

By  Frank  A.  Craig,  1V[.D. 

Acute  and  Subacute  Bronchitis,  325;  Chronic  Bronchitis,  332;  Fibrinous 
Bronchitis,  337;  Bronchiectasis,  339;  Bronchial  Asthma,  349;  Hay-fever 
and  Hay-asthma,  358;  Emphysema,  361;  Pulmonary  Tuberculosis,  371; 
Chronic  Non-tuberculous  Pulmonary  Infections,  472;  Pulmonary  Con- 
gestion, 474;  Pulmonary  Edema,  476;  Pulmonary  Abscess,  478;  Pulmon- 
ary Gangrene,  484;  Pneumoconiosis,  486;  Pulmonary  Syphilis,  489; 
Pulmonary  Actinomycosis,  493;  Pulmonary  Streptothricosis,  494;  Pul- 
monary Neoplasm,  495;  Echinococcus  Disease  of  the  Lungs,  497;  Pleural 
Fluids,  499;  Acute  Fibrinous  Pleuritis,  502;  Serofibrinous  Pleuritis,  509; 
Purulent  Pleuritis,  521;  Hemorrhagic  Pleuritis,  526;  Pleural  Neoplasms, 
526;  Hydrothorax,  528;  Hemothorax,  528;  Chylothorax,  529;  Pneumo- 
thorax, 529;  Bacterins  in  the  Treatment  of  Diseases  of  the  Lungs, 
Bronchi,  and  Pleura,  534. 

Diseases  of  the  Kidneys, 541 

By  JuDSON  Daland,  M.D.,  and 
Francis  J.  Dever,  M.D. 

General  Considerations,  542;  Displacements  of  the  Kidneys,  553;  Anom- 
alies of  Urinary  Secretion,  561;  Circulatory  Disturbances  of  the  Kidneys, 
574;  Nephritis,  578;  Chronic  Parenchymatous  Nephritis,  589;  Chronic  In- 
terstitial Nephritis,  599;  Nephrolithiasis,  619;  Hydronephrosis,  625; 
Pyogenic  Infections  of  the  Kidneys,  626;  Perinephritic  Abscess,  632; 
Tuberculosis  of  the  Kidney,  633;  Tumors  of  the  Kidney,  639;  Congenital! 
Cystic  Degeneration  of  the  Kidneys,  639. 

Diseases  of  the  Digestive  System,    .        .        .     643 

By  B.  B.  Vincent  Lyon,  A.B.,  M.D.,  and 
Louis  Lehrfeld,  A.M.,  M.D. 

Disieases  of  the  Mouth  as  Related  to  General  Systemic  Diseases,  643;  Fis- 
sures of  the  Lips,  648;  Herpes  Labialis, -649;  Foul  Breath,  650;  Gingivitis, 
650;  Pyorrhea  Alveolaris,  651;  Catarrhal  Stomatitis,  655;  Aphthousi 
Stomatitis,  656;  Bednar's  Aphthee,  658;  Thrush,  658;  Ulcerative  Stoma- 
titis, 659;  Gangrenous  Stomatitis,  661;  Mercurial  Stomatitis,  662;  Car- 
riers, 663;  Epidemic  Sore  Throat,  665;  Syphilitic  Affections  of  the  Mouth, 
666;  Gonorrhea  of  the  Mouth,  667.  Diseases  of  the  Tongue:  Acute 
Glossitis^  668;  Chronic  Glossitis,  669;  Sublingual  Ulcer,  671;  Tumors  of 
the  Tongue,  671;  Macroglossia,  672.  Diseases  of  the  Salivary  Glands 
Ptyalism,  672;  Xerostoma,  672;  Inflammation  of  the  Parotid  Glands,  672 
Salivary  Calculi,  673;  Ludwig's  Angina,  674.  Diseases  of  the  Esophagus 
Acute  Esophagitis,  674;  Ulcer'  of  the  Esophagus,  675;  Carcinoma  of  the 
Esophagus,  677;  Esophagismus,  678;  Diverticulum  of  the  Esophagtis, 
679:   Foreign  Bodies,   681;   Stricture  of  the  Esophagus,   681.     Diseases  of 


CONTENTS.  vii 

PACK 
the  Stomach  and  Duodenum:  Ulcer  of  the  Stomach  and  Duodenum, 
684;  Carcinoma  of  the  Stomach,  724;  Saircoma  of  the  Stomach,  716;  Gas- 
tritis, 749;  Alcoholic  Gastritis,  779;  Syphilis  Of  the  Stomach,  780;  Tuber- 
culosisi  of  the  Stomach,  789;  Pylorospasmi,  796;  Pyloric  Obstruction,  801; 
Congenital  Pyloric  Stenosis,  804;  Cardiospasm,  810;  Gastrectasis,  818; 
Gastric  Crises  of  Cerebrospinal  Syphilis,  826.  Diseases  of  the  Intestines: 
Acute  Enteritis,  837;  Chronic  Enteritis,  839;  Enteritis  in  Infants,  841; 
Cholera  Infantum,  844;  Acute  Colitis,  845;  Chronic  Mucous  Colitis,  845; 
Ulcerative  Colitis,  848;  Appendicitis,  849;  Constipation,  S54;  Intestinal 
Obstruction,  859;  Enteroplosis,  Visceroptosis,  Splanchnoptosis,  862;  In- 
testinal Neuroses,  867;  Carcinoma  of  the  Intestine,  869;  Tuberculosis' 
of  the  Intestine,  871;  Syphilis  of  the  Intestine,  872.  Diseases  of  the 
Liver:  General  Considerations.,  874;  Biliousness,  875;  Jaundice,  877; 
Catarrhal  Jaundice,  877;  Acute  Infectious  Jaundice,  881;  Acute  Chole- 
cystitis, 890;  Gall-stones,  892;  Chronic  Cholangitis  and  Chronic  Choleli- 
thiasis, 894;  Cirrhosis  of  the  Liver,  898;  Abscess  of  the  Liver,  905; 
Acute  Yellow  Atrophy  of  the  Liver,  908;  Fatty  Degeneration  of  thei 
Liver,  909;  Patty  Infiltration  of  the  Liver,  910;  Amyloid  Disease  of  the 
Liver,  911;  Syphilis  of  the  Liver,  912;  Tuberculosis  of  the  Liver,  913; 
Tumors  of  the  Liver,  913.  Diseases  of  the  Pancreas:  General  Con- 
siderationsi,  914;  Pancreatic  Hemorrhage,  916;  Acute  Pancreatitis,  916; 
Chronic  Pancreatitis,  918;  Pancreatic  Calculi,  919;  Pancreatic  Cysts, 
920;  Carcinoma  of  the  Pancreas,  921. 


Diseases  of  the  Peritoneum,      ....     927 

By  WiLMER  Krusen,  M.D.,  LL.D.,  F.A.C.S. 

Acute  General  Peritonitis,  927;  Chronic  Peritonitis,  945;  Non-exudative 
Chronic  General  Peritonitis,  952;  Pelvic  Peritonitis,  953;  Appendicular 
Peritonitis,  959;  Subphrenic  Abscess,  960;  Peritoneal  Neoplasms  963; 
Ascites,  966. 


Diseases  of  the  Blood, 


FOREWORD. 

The  progress  of  hematolog-y  during  the  past  few  years  has 
added  greatly  to  our  ability  to  treat  more  intelligently  those 
somewhat  poorly  defined  disorders  classified,  more  or  less 
arbitrarily,  as  Diseases  of  the  Blood. 

The  treatment  of  a  given  anemia  should  be  determined  by 
intelligent  inquiry  as  to  the  exact  nature  of  the  morbid  proc- 
ess, an  investigation  that  at  times  calls  for  a  correlation  of 
data  relating  to  every  potential  etiologic  factor,  to  information 
derived  from  a  careful  physical  examination,  and  to  the  sug- 
gestions furnished  by  the  blood  report.  To  advise  iron  merely 
because  pallor  happens  to  be  the  leading  clinical  feature  of  the 
patient  is  about  as  rational  therapy  as  to  expect  to  cure  con- 
stipation by  prescribing  a  laxative  without  search  for  the 
underlying  factor  of  a  sluggish  bowel.  In  the  treatment  of 
an  anemia,  therefore,  its  identity  must  be  established ;  the 
exciting  factor  removed,  if  possible ;  and  the  blood  deteriora- 
tion remedied  by  appropriate  hematinics,  nutritious  dietary, 
and  observance  of  sane  hygienic  rules.  This  routine  applies 
in  general  to  the  treatment  of  all  types  of  blood  disorders — 
primary,  secondary,  and  belonging  to  the  ill-defined  inter- 
mediate group.  Thus,  while  in  virtually  all  of  these  clinical 
entities  iron  and  a  ferruginous  ration  are  useful,  in  certain  of 
them  arsenic,  by  the  mouth  or  in  the  form  of  salvarsan,  is 
indicated ;  while  in  still  others  nothing  short  of  blood  trans- 
fusions, radiation,  or  splenectomy  can  be  relied  upon,  even  as 
a  palliative  step. 

In  the  following  pages  the  reader's  knowledge  of  modern 
hematology  is  presupposed,  and  laboratory  technic  relating 
thereto  is  omitted,  but  the  relevant  facts  of  the  clinical  path- 
ology and  diagnosis  of  the  disease  under  discussion  are  briefly 
rehearsed   with   the   intention    thus   to   present   a   reasonable 

(3) 


4  DISEASES    OF    THE    BLOOD. 

basis  for  the  therapeutic  measures  subsequently  advised. 
These  are  presented  in  some  detail  and  explicit  directions 
g-iven,  whenever  the  technical  methods  advised  justify  so 
doing. 

The  choice  of  drugs  and  the  method  of  their  administra- 
tion have  been  determined  largely  by  the  author's  personal 
experience  in  various  types  of  anemia,  but  current  practice 
has  not  been  lost  sight  of,  and  the  newer  special  therapeutic 
procedures  of  real  utility  have  been  given  attention  commen- 
surate with  their  value. 

Hayem's  dictum  that  "I'avenir  appartient  a  I'hematologie" 
perhaps  does  not  merit  literal  acceptance,  but  it  is  an  obvious 
truth  that  hematology  occupies  a  leading  place  in  modern 
clinical  medicine,  and  that  the  successful  treatment  of  blood 
diseases  assumes  on  the  part  of  the  physician  an  intimate 
appreciation  of  the  underlying-  pathologic  defects  of  such  dis- 
orders, and  an  intelligent  understanding  of  the  various  meth- 
ods designed  for  their  control.  With  these  phases  of  the  sub- 
ject this  section  deals,  it  is  to  be  hoped,  succinctly  and  prac- 
tically, so  that  the  reader  shall  obtain  helpful  information, 
rather  than  theoretic  discussion  of  moot  points. 

SYMPTOMATIC  SECONDARY  ANEMIA. 

As  its  name  implies,  this  condition  arises  as  a  result  of 
pathologic  change  elsewhere  in  the  body;  in  this  sense  it  is 
secondary.  It  is  symptomatic  in  that  the  anemia  is  but  a 
symptom  provoked  by  an  underlying  condition,  and  in 
this  respect  it  is  to  be  distinguished  from  the  primary  anemias, 
such  as  chlorosis,  pernicious  anemia,  splenic  anemia,  and  the 
leukemias,  which  arise  as  initial  conditions,  the  cause  of 
which  is  unknown.  It  is  that  form  of  anemia  which  is  most 
frequently  encountered  by  the  physician. 

Thus,  from  a  clinical  viewpoint  it  is  convenient,  even  if  not 
accurately  scientific,  to  group  under  secondary  anemias  those 
forms  of  blood  deterioration  whose  origin  and  persistence  is 
tangibly  referable  to  an  adequate  exciting  cause,  the  removal 
of  which,  plus  the  intelligent  use  of  proper  food  and  hema- 
tinics  promptly  excites  regeneration  of  the  blood  along  normal 
lines. 

Such   a   clinical   classification   as  the   foregoing,   therefore, 


SYMPTOMATIC    SECONDARY    ANEMIA.  5 

excludes  from  the  secondary  anemias  all  those  types  of  blood 
deterioration  which  to  all  intents  and  purposes  may  be  re- 
garded as  genuine  idiopathic  processes,  and  whose  origin  is 
based  upon  no  discoverable  cause.  To  this  group,  which 
are  termed  the  primary  anemias,  belong  chlorosis,  primary 
pernicious  anemia,  and  leukemia;  and  with  these  idiopathic 
varieties  of  blood  diseases  most  clinicians  also  include  several 
obscure  morbid  processes  which,  although  characterized  by 
conspicuous  blood  changes,  do  not  properly  come  under  the 
heading  of  the  essential  anemias.  To  this  third  and  indeter- 
minate class  belong  Hodgkin's  disease,  splenic  anemia,  chlo- 
roma,  and  infantile .  pseudoleukemia  anemia.  Finally,  ery- 
thremia, purpura,  and  the  hemorrhagic  diatheses  are  definite 
blood  disorders,  and  although  they  lack  a  consistent  blood 
picture,  are  naturally  classified  arbitrarily  in  connection  with 
diseases  of  the  blood.  It  is  with  the  foregoing  types  of  clin- 
ical disorders  that  the  present  section  deals. 

Among  the  causes  of  symptomatic  secondary  anemia  are 
such  readily  understood  factors  as  a  loss  of  blood;  it  may 
also  include  those  dyscrasias  which  arise  from  malnutrition; 
those  due  to  the  absorption  of  metallic  poisons,  such  as  lead ; 
those  induced  by  toxins  generated  during  the  course  of  acute 
and  chronic  infections;  and  those  referable  to  the  hemolytic 
effect  brought  about  by  high  fevers.  Bright's  disease,  with  its 
attendant  defects  of  nutrition,  produces  a  secondary  anemia; 
cancer  acts  in  a  similar  manner,  as  also  does  syphilis,  malarial 
fevers,  and  numerous  other  infectious  processes. 

The  essential  feature,  then,  of  a  symptomatic  secondary 
anemia  is  that  it  shall  arise  as  a  symptom  of,  and  secondary  to, 
ascertainable  metabolic  changes  elsewhere  in  the  economy. 

The  blood  picture  undergoes  a  variety  of  changes,  varying 
in  intensity  with  the  chronicity  and  virulence  of  the  under- 
lying causative  condition.  Anemias  due  to  simple  defects  of 
nutrition  may  show  but  a  trifling  deficiency  of  the  hemoglobin 
content,  with  a  commensurate  loss  of  erythrocytes,  and  with 
but  a  moderate,  if  any,  degree  of  leucocytosis.  When,  how- 
ever, toxic  factors  are  the  underlying  cause,  the  hemoglobin 
and  erythrocytes  are  more  decidedly  subnormal,  and  the  num- 
ber of  leucocytes  is  proportionately  increased.  In  lead  poison- 
ing it  is  common  to  find  a  50  per  cent,  loss  of  hemoglobin  and 


6  DISEASES    OF    THE    BLOOD. 

erythrocytes.  The  secondary  anemias  which  arise  in  con- 
sequence of  intestinal  parasites  cause  a  profound  change  in  the 
blood,  the  picture  frequently  resembling  pernicious  anemia  to 
such  a  degree  that  the  differentiation  is  based  solely  upon  the 
fact  that  the  blood  gradually  returns  to  normal  after  the  com- 
plete expulsion  of  the  parasite. 

The  marked  pallor  of  the  skin  and  mucous  membranes 
first  attracts  the  attention  of  the  physician.  Following  hemor- 
rhages, the  patient  may  complain  of  a  faint  and  giddy  feeling 
and  of  noises  in  the  ears ;  disordered  vision,  labored  breathing, 
mental  confusion,  rapid  action  of  the  heart,  with  a  faint  pulse, 
and  a  sense  of  early  exhaustion  are  frequently  added  to  the 
clinical  picture. 

So-called  hemic  murmurs,  audible  particularly^  at  the  base 
of  the  heart,  and  a  venous  hum  over  the  course  of  the  external 
jugular  veins  are  additional  signs  of  diagnostic  value  in  many 
of  the  high-grade  anemias  of  secondary  origin. 

TREATMENT. 

The  first  step  in  the  treatment  of  symptomatic  secondary 
anemia  is  to  identify  and  then  to  remove  the  underlying  cause. 
If  mialaria  be  the  provocative  factor,  quinin  is  indicated ;  if 
the  anemia  be  secondar}-  to  syphilis  the  iodids  or  salvarsan 
are  to  be  exhibited ;  if  hook-worm  be  the  cause,  thymol  will 
be  administered ;  if  cancer  lies  at  the  root  of  the  trouble,  the 
knife  is  to  be  employed ;  if  an  abscessed  tooth,  long  unsus- 
pected and  continuing  for  years,  has  been  productive  of  the 
hemolytic  change,  the  care  of  a  competent  dentist  is  neces- 
sary before  the  reconstruction  of  the  blood  by  dietan,',  phar- 
maceutic, and  hygienic  measures  is'  undertaken. 

Dietetics.  Nutritious  food,  properly  assimilated,  is,  of 
course,  the  natural  blood-builder.  Lost  appetite  may  be  re- 
gained by  skill  in  the  preparation  of  food,  by  the  use  of  ap- 
petizing condiments,  and  by  advising  stomachics  such  as  gen- 
tion,  quassia,  cimicifuga,  and  nux  vomica.  Meats,  milk,  eggs, 
and  fats  are  indicated,  combined  in  a  proper  proportion  with 
starchy  foods  and  green  vegetables  in  a  normal,  rational  meal. 
The  dietary  is  never  to  be  limited  to  any  one  particular 
variety  of  food,  and  broad,  well-balanced  meals  are  to  be  given 
the  anemic  subject.    Veal,  ham,  and  pork  have  a  tendency  to 


SYMPTOMATIC    SlCCONDAin'    ANEMIA.  7 

upset  digestion,  and  rich  gravies,  hot  breads,  cakes,  and  an 
excess  of  candy  may  do  more  harm  than  good. 

Drug  Therapy.  Iron  is  the  hematinic  par  excellence  in  the 
treatment  of  secondary  anemias.  It  has  been  estimated  that 
the  body  requires,  for  physiologic  processes,  ^/^  of  a  grain 
(0.00810  Gm.)  of  iron  each  day.  To  replace  the  systemic  loss 
of  this  element,  iron  may  be  exhibited  in  the  form  of  Blaud's 
pill,  consisting  of  5  grains  (0.324  Gm.)  of  carbonate  of  iron, 
so  prepared  that  the  drug  is  not  permitted  to  oxidize  or  react 
until  it  reaches  the  stomach.  (See  p.  12.)  Tincture  of  the 
chlorid  of  iron,  once  deservedly  popular,  is  rarely  used  now- 
adays on  account  of  its  distinctly  deleterious  effect  upon  the 
teeth,  it  being  almost  impossible  to  administer  this  drug,  or  to 
sv^^allow  it,  without  it  coming  in  contact  with  the  denture. 
Arsenic  may  be  combined  with  iron  when  the  number  of  the 
erythrocytes  is  subnormal,  Fowler's  solution  {Liquor  potassii 
arsenitis)  may  be  employed,  beginning  with  initial  doses  of  3 
drops  after  meals,  increased  1  drop  a  day  until  the  symptoms 
of  physiologic  tolerance  appear. 

Or  ampules  of  sodium  cacodylate,  each  containing  0.20  Gm. 
(3  grains)  to  the  mil  (16  m.)  may  be  used  in  preference  to  the 
foregoing  preparation  of  arsenic.  It  is  the  author's  practice  to 
give,  by  intramuscular  injection,,  a  series  of  twelve  doses  of 
this  preparation,  on  alternate  days,  beginning  with  a  dosage 
of  0.032  Gm.  (^  grain),  and  increasing  by  this  quantity  with 
subsequent  injections  until  a  maximum  of  0.13  Gm.  (2  grains) 
is  attained. 

Iron  citrate,  given  hypodermically,  is  much  vaunted  in 
secondary  anemias,  and  justly  so,  inasmuch  as  this  manner  of 
administering  the  metal  robs  its  use  of  the  many  by-effects  so 
constantly  arising  from  taking  iron  by  the  mouth.  The  proper 
technic  of  the  intramuscular  use  of  iron  is  dealt  with  under  the 
discussion  of  Chlorosis  (page  12). 

A  hygienic  manner  of  living  will  aid  in  the  early  restora- 
tion of  the  anemic  subject.  Fresh  air,  deep  breathing,  moder- 
ate exercise,  life  in  the  open,  attention  to  the  organs  of  elimina- 
tion, frequent  baths  followed  by  vigorous  rubbing  are  all  part 
and  parcel  of  the  rational  treatment  of  a  secondary  anemia  of 
any  type. 


DISEASES    OF   THE   BLOOD. 


CHLOROSIS. 


In  chlorosis  the  typical  features  of  the  blood  picture  show 
an  unnaturally  subnormal  hemoglobin  figure,  with  little  or 
no  loss  of  erythrocytes,  a  virtually  normal  leucocyte  count, 
and  a  decided  increase  of  the  volume  of  the  blood  plasma 
which  retains  its  normal  density.  The  disease  reflects  a  re- 
tardation of  hemogenesis,  the  exact  mechanism  of  which  is 
conjectural,  although  several  attractive  hypotheses  have  been 
suggested  upon  which  to  build  up  an  intelligent  working 
"knowledge  of  its  nature.  Of  these  the  theory  advanced  by  E. 
Lloyd  Jonesi  is  both  reasonable  and  largely  substantiated  by 
clinical  evidence.  He  suggests  that  a  hypersecretion  of  the 
female  sexual  organs  is  the  active  factor  of  the  chlorotic  state, 
and  that  the  blood  of  women  thus  affected  in  reality  represents 
exaggerated  fertility,  or  the  accumulation  of  abundant  ma- 
terial designed  for  fetal  nutrition  during  the  period  of  preg- 
nancy. 

Closely  related  to  the  foregoing  hypothesis  is  the  theory 
advanced  by  Von  Jagic,^  who  believed  that  the  chlorotic 
symptom-complex  is  a  constitutional  anomaly  arising  from 
disturbances  of  the  internal  secretions,  chiefly  of  the  genital 
organs,  but  also  implicating  the  other  ductless  glands. 

Bunge's  hypothesis,  as  elaborated  by  Stockman,3  is  based 
upon  the  premises  that  in  the  chlorotic  subject  the  presence 
in  the  bowel  of  an  excess  of  sulphurated  hydrogen  and  alka- 
line sulphids  materially  interferes  with  the  absorption  of  the 
organic  iron  of  the  ingested  food,  by  converting  it  into  an 
insoluble  inorganic  ferruginous  sulphid.  This  chemical  in- 
terchange deprives  the  blood  of  its  necessary  ration  of  iron, 
with  the  result  that  hydrogen  formation  is  insufficient,  and 
hence  the  instrumental  determination  of  this  pigment  shows 
abnormally  low  percentages,  and  the  colored  cellular  elements 
of  the  blood  are  correspondingly  pale.  On  the  other  hand, 
in  chlorosis  the  administration  of  inorganic  iron,  which  itself 
cannot  be  absorbed,  combines  with  and  neutralizes  the  sul- 
phurated hydrogen,  so  that  the  organic  food  iron,  thus  pro- 
tected, can  undergo  unhampered  absorption  and  hydrogen 
manufacture.  Bunge's  theory,  referred  to  chiefly  because  of 
its  historical  interest,  is  ingenious,  but  too  paradoxical  for  ere- 


CHLOROSIS.  9 

deuce,  especially  in  the  light  of  our  more  recent  knowledge  of 
the  physical  chemistry  of  the  organic  and  inorganic  iron 
compounds. 

Similarly,  one  dismisses  as  inadequate  the  one-time  pop- 
ular theories  attributing  chlorosis  to  Virchow's  mesoblastic 
hypoplasia,  or  an  arrest  of  development,  affecting  the  entire 
arterial  system  and  the  hemogenetic  organs ;  to  recurrent 
hemorrhages,  particularly  of  the  uterine  and  the  gastric  sur- 
faces ;  to  various  disorders  of  the  sexual  apparatus ;  and  to  a 
form  of  toxic  hemolysis  variously  attributed  to  intestinal  and 
gastric  decomposition. 

Beyond  all  reasonable  doubt,  however,  is  the  fact  that  true 
chlorosis  is  restricted  to  the  female  sex.  So-called  "chloritic 
blood"  by  no  means  indicates  chlorosis,  in  the  absence  of  a 
chlorotic  symptom-complex,  and  this  error  doubtless  accounts 
for  the  reported  occurrence  of  this  type  of  primary  anemia  in 
males;  it  is  about  as  compatible  as  is  pregnancy  in  men,  who, 
despite  predominantly  low  hemoglobin  values,  absolutely  lack 
the  other  details  of  the  clinical  picture  grouped  under  the 
disease  in  question. 

Chlorosis,  then,  occurs  only  in  females,  usually  those  in 
early  adolescence  at  or  near  the  period  of  puberty,  or,  if  met 
with  in  later  life,  in  women  whose  menstrual  periods  habit- 
ually have  been  scanty  or  painful. 

The  chlorotic  girl,  who  more  often  than  not  is  a  blonde, 
given  to  ready  blushing,  is  pale,  short  of  breath,  and  appar- 
ently well  nourished.  The  pallor  in  the  vast  majority  of  in- 
stances is  distinguished  by  no  peculiarities  other  than  an 
obviously  pallid  skin  and  blanched  mucosal  surfaces ;  excep- 
tionally, it  conforms  more  happily  to  the  classical  (and  hack- 
neyed) coloring  of  "green  sickness,"  and  in  an  occasional 
example  of  "chlorosis  fllorida"  or  "rubra"  vivid  patches  of  color 
on  the  cheeks  contrast  with  the  alabaster  pallor  of  the  face, 
the  whiteness  of  the  ears  and  lips,  and  the  steel  blue  tint  of 
the  sclerotics.  The  dyspnea,  referable  to  bulbar  stimulation 
by  the  insufficiently  oxidized  blood,  is  a  conspicuous  symptom 
and  one  that  to  the  patient  is  a  source  of  great  concern.  Most 
chlorotics  retain  the  graceful  contour  of  feminine  adolescence 
and  look  fully  nourished,  despite  their  pallid  face,  and  in 
some  this  appearance  is  exaggerated  by  a  dropsical  pufifiness. 


10  DISEASES    OF    THE   BLOOD. 

Of  gastro-intestinal  symptoms,  constipation,  chronic  in- 
digestion, with  anorexia,  heavy  breath,  and  annoying  pyrosis, 
are  important ;  and  considerable  dilatation  of  the  stomach  is 
a  common  complaint.  Gastric  ulcer,  probably  due  to  un- 
natural vulnerability  of  the  gastric  mucosal  lining,  is  a  not 
infrequent  complication  which  may  persist  stubbornh^  as  a 
leading  clinical  feature.  The  appetite  is  most  capricious,  and 
varies  from  time  to  time,  complete  anorexia  alternating  with 
a  ravenous  desire  to  eat,  and  with  a  pen-erted  craving  for 
foods  such  as  pickles  and  lemons  and  candy. 

Functional  nervous  disorders  are  most  common — tearful- 
ness, introspection,  caprice,  melancholy,  and,  exception- 
ally, actual  outbursts  of  hysteria  may  develop  to  worry  the 
patient's  family,  and  tr}^  her  medical  adviser.  The  familiar 
"hysterical  bark''  is  attributable  to  chlorosis  rather  than  to 
hysteria  by  Albutt.^  who  significantly  refers  to  the  cure  of 
such  coughs  by  iron. 

Circulatory  disturbances  are  the  predominant  clinical 
features  of  many  chlorotics,  and  are  present  in  all,  to  a  more 
or  less  marked  degree.  Venous  hums  (bruit  de  diahle ;  vcnen- 
sauscn  )  generated  in  the  jugular  veins,  especially  the  right,  are 
audible  at  the  base  of  the  sternomastoid  muscle,  as  a  contin- 
uous vibratory  sound,  visibly  intensilied  by  the  erect  posture, 
by  moderate  pressure,  and  by  inspiration.  Functional  mur- 
murs at  the  cardiac  base  and  at  the  apex  are  common,  par- 
ticularly in  the  pulmonic  area.  Enlargement  of  the  cardiac  area 
is  practically  constant,  and  undue  arterial  and  venous  pulsa- 
tions frequently  occur.  \'enous  thrombosis  is  a  grave,  but 
fortunately  a  rare,  complication. 

There  is  a  moderate  enlargement  of  the  thyroid  gland  in 
many  cases,  and,  less  commonly,  the  spleen  is  definitely  en- 
larged ;  in  others  one  sees  a  t3^pical  Joffroy's  sign — ^absence  of 
horizontal  wrinkling  of  the  forehead  when  the  subject  glances 
at  the  ceiling  without  moving  the  head. 

TREATMENT. 

The  action  of  iron  in  chlorosis  is  an  example  of  the  specific 
action  of  a  drug,  for  no  case  of  this  type  of  primar\^ 
anemia  fails  to  recover  with  the  intelligent  use  of  iron,  and,  on 


CHLOROSIS.  11 

tlie  other  hand,  none  can  recover  without  it.  Iron,  then,  is 
the  basis  of  cure  of  this  condition,  and  from  the  effect  of  this 
metal  one  can  confidently  anticipate  prompt  restoration  of 
the  blood  picture  to  normal,  and  the  complete  relief  of  the 
symptoms,  alike  distressing-  to  the  patient  and  to  the  medical 
attendant. 

As  to  the  best  form  of  iron  to  be  used  in  chlorosis,  most 
authorities  prefer  the  time-honored  Blaud's  pill  of  the  car- 
bonate (Pilulcc  ferri  c'arbonatis) ,  for  administration  by  the 
mouth.  This  is  by  all  odds  the  most  satisfactory  form  of 
iron  to  be  employed  for  the  cure  of  chlorosis,  inasmuch  as  its 
astringent  properties  are  mild  and  its  long-continued  use 
does  not  tend  to  produce  unpleasant  effects  such  as  headache, 
indigestion,  and  constipation.  Should,  however,  the  bowels 
become  sluggish  after  the  prolonged  use  of  this  form  of  iron 
the  pill  may  be  combined  with  moderate  doses  of  cascara 
sagrada  or  with  phenolphthalein,  or,  if  thought  advisable,  the 
bowels  may  be  kept  free  by  the  use  of  a  good  sour  milk,  as 
advised  by  certain  Continental  authorities;  or  baker's  yeast 
may  be  used  to  counteract  this  tendency,  and  for  this  purpose 
half  a  cake  of  yeast  dissolved  in  a  tumblerful  of  cold  water 
should  be  taken  twice  daily. 

Excessive  ferruginazation  is  no  longer  reg^arded  as  good 
.practice,  but  unfortunately,  where  therapeutic  tradition  rules, 
this  mistake  is  still  practised  to  some  extent.  The  average 
patient  can  take,  without  disconcerting^  by-effects,  approxi- 
mately three  or  four  Blaud's  pills  daily  for  the  first  week,  six 
pills  daily  for  the  second,  and  from  nine  to  twelve  daily  for 
the  third  week,  and  thereafter  until  the  blood  picture  returns 
to  normal.  Discontinuance  of  the  iron  should  be  gradual,  at 
the  rate  inverse  to  that  governing  its  progressive  increase 
during  the  initial  few  weeks  of  treatment.  According  to  the 
plan  just  outlined,  7>4  grains  (^  Gm.)  of  iron  are  given 
daily  during  the  first  week,  15  grains  (1  Gm.)  daily  during  the 
second  week,  and  about  22^  grains  (1.5  Gm.)  daily  for  the 
third  week,  and  thereafter  until  a  cure  is  effected.  This 
amount  of  iron  is  usually  well  tolerated,  without  the  fear  of 
any  discomfort  to  the  patient;  it  is  needless  to  add  that  this 
dosage  is  more  than  amply  sufficient  for  the  purposes  sought 
— to  stimulate  hematopoiesis,  to  store  up  an  excess  of  iron  in 


12  DISEASES    OF    THE    BLOOD. 

the  body  for  subsequent  absorption,  and  to  preserve  chemic- 
all}-  the  food  iron  in  the  intestinal  canal. 

The  ordinar\-  Blaud's  pill  as  purchased  in  the  drug  store 
may  be  absolutely  inert,  and  fail  utterly  to  meet  the  essential 
conditions  just  named  in  the  preceding  paragraph.  It  may 
represent  but  an  irritant  oxid,  in  view  of  which  it  is  best,  if 
one  is  not  sure  of  the  exact  effect  of  the  average  "stock"  pill, 
that  the  metal  should  be  prepared  freshly  by  the  druggist  in 
small  quantities.  An  exceptional!}^  active  Blaud's  pill,  very 
popular  in  Great  Britain,  is  so  compounded  that  no  interaction 
"of  its  ingredients  occurs  until  it  is  acted  upon  by  the  gastric 
juice,  as  a  result  of  which  action  a  nascent  carbonate  is  pro- 
duced in  a  readily  absorbable  form, 

If  for  anv  reason  Blaud's  pill  should  be  contraindicated  in 
the  individual  case,  the  citrate  of  iron  may  be  used  instead,  by 
intramuscular  injection.  This  of  course  obviates  all  the  pos- 
sible ill  effects  of  oral  administration,  furnishes  an  imme- 
diate source  of  iron  to  the  chlorotic  .blood,  and  obviates  all 
effects  of  this  metal  upon  the  teeth,  the  stomach,  and  the  gut. 
Ampules  containing  3  grains  (0.195  Gm.)  of  citrate  of  iron  are 
on  the  market ;  used  in  connection  with  a  No.  3  hypodermic 
needle  and  a  Leur  type  syringe,  injections  deep  into  the  deltoid 
muscle  are  made  without  pain  or  other  discomfort  to  the  pa- 
tient. As  a  rule,  it  is  sufficient  to  give  these  injections  on 
alternate  days. 

Some  authorities  prefer  to  substitute  for  Blaud's  pill  sul- 
phate of  iron  in  1-grain  (0.065  Gm.)  pills  during  the  first  week 
of  treatment,  this  initial  dosage  to  be  doubled  and  trebled 
as  the  treatment  progresses.  AVith  this  form  of  iron,  however, 
gastric  disturbances  and  constipation  are  much  more  likely  to 
occur  than  with  the  two  forms  of  iron  just  described. 

In  patients  with  habitual  loss  of  appetite,  it  may  be 
thought  better  to  choose  the  alcoholic  liquid  iron  as  repre- 
sented by  the  tincture  of  the  chlorid. 

There  is  no  excuse  whatever  for  resorting  to  the  expensive 
proprietary  organic  irons,  for  none  of  them  gives  more 
adequate  results  than  the  forms  just  mentioned,  and  with  none 
Is  the  hemoglobin  increase  more  rapid  and  more  stable  than  it 
is  when  one  of  the  standard  iron  salts  is  used. 

In  addition  to  iron,  arsenic  is  indicated  in  manv  chlorotic 


CHLOROSIS.  13 

girls  to  counteract  the  subnormal  number  of  erythrocytes. 
Of  course  the  demand  is  not  great,  inasmuch  as  the  count  of 
cells  is  but  moderately  subnormal,  but  in  order  to  start  the 
upward  wave  toward  an  excess  of  blood  constituents,,  it  is 
wise  to  use  some  form  of  arsenic,  such  as  Fowler's  solution  or 
arsenous  acid  in  order  to  accomplish  this  end.  Thus  the  use 
of  from  2  to  10  drops  (0.133  to  0.666  mil)  of  Liquor  potassii 
oi'scnitis  thrice  daily  exerts  an  active  stimulus  of  the  bone 
marrow,  excites  adequate  secretion  of  the  thyroid  gland,  and 
provokes  neither  g'astric  nor  renal  irritation,  except  in  highly 
susceptible  subjects;  arsenous  acids,  if  chosen,,  should  be  given 
three  times  a  day  in  doses  of  Y^q  grain  (0.002  Gm.). 

Although  iron  is  the  specific  for  chlorosis,  other  therapeutic 
measures  must  receive  d,ue  consideration  so  as  to  deal  ade- 
quately with  the  peculiar  symptom-complex.  The  special 
symptoms  relating  to  the  chlorotic  condition  include  a  long 
medley  of  complaints,  both  real  and  imaginary,  and  the  cor- 
rection of  these  symptoms,  individually  of  no  great  moment 
save  to  the  patient  herself,  is  a  detail  of  treatment  which 
should  not  be  dispensed  with  in  the  face  of  favorably  pro- 
gressing blood  reports. 

Rest  in  bed  is  just  as  essential  as  the  use  of  iron,  and  by 
this  is  meant  a  literal  rest,  without  any  physical  exertion 
whatever,,  and  with  an  environment  such  as  to  banish  care, 
worry  and  all  contributing  factors  of  a  disturbing  character. 
Particularly  is  rest  desirable  in  chlorotics  with  prominent 
cardiovascular  symptoms,  in  whom  complete  physical  relaxa- 
tion, aside  from  its  other  good  effects,  may  entirely  eliminate 
distressing  complaints,  such  as  dyspnea,  vertigo,  cardiac  pal- 
pitation, and  edema.  After,  say,  a  fortnight  or  three  weeks  of 
absolute  confinement  to  bed,  and  after  decided  improvement 
of  the  subjective  symptoms  has  occurred,  the  patient  may  be 
advised  to  spend  her  mornings  in  bed,  and,  if  weather  con- 
ditions permit,  to  pass  the  greater  part  of  the  afternoon  out- 
doors in  the  sunshine.  Active  physical  exercise  is  a  great 
mistake,  for  the  chlorotic's  languor  and  asthenia,  despite  her 
apparent  good  nourishment,  are  real,  and  readily  aggravated 
by  physical  exertion. 

In  conjunction  with  the  foregoing  measures,  systematic 
hydrotherapy  and  massage  are  most  useful.     In  the  patient's 


14  DISEASES    OF    THE    BLOOD. 

own  home  this  regime  may  consist  simply  of  a  twenty-minute 
hot  104°  F.  (40.0°  C.)  tub  bath,  followed  by  a  cool  or  cold 
douche,  a  brisk  rub,  and  an  hour's  rest. 

As  to  the  dietary,  one  should  aim  to  provide  a  high  content 
of  proteins  and  fats.  Unfortunately,  the  average  case  of  chlo- 
rosis shows  a  pronounced  aversion  to  the  very  source  of  food 
demanded  by  her  thin  blood.  Moreover,  the  digestive  dis- 
orders, so  commonly  the  conspicuous  symptoms  of  the  case, 
further  interfere  with  the  institution  of  a  dietary  demanded  by 
the  underlying  condition.  The  use  of  the  various  digestive 
enzymes,  and,  in  extreme  cases,  of  lavage,  tend  to  counteract 
these  defects.  As  to  the  most  useful  kind  of  diet  to  be  pre- 
scribed in  chlorosis,  a  full  ration  of  butter,  clotted  Devonshire 
cream,  rich  raw  milk,  and  eggs  shoi4,ld  be  the  mainstay  of  the 
dietary.  If  raw  milk  disagrees  with  the  patient,  lactic  acid 
milk  prepared  with  pure  Bulgarian  cultures,  or  peptonized 
milk  are  useful  substitutes.  Overfeeding  with  milk  and  eggs 
should  be  carefully  avoided,  and  the  exact  quantity  for  each 
day's  feeding  is  to  be  determined  in  the  individual  case,  with 
due  regard  to  personal  adaptability.  In  addition  to  butter,  the 
use  of  fat  in  the  form  of  crisp  fried  bacon  is  generally  well 
relished  and  digested ;  only  exceptionally  must  one  give  f a.ts  in 
such  a  distasteful  form  as  codliver  oil  or  olive  oil. 

The  free  use  of  beef,  served  rare,  should  supplement  the 
measures  alread}^  indicated.  The  average  patient  can  be  in- 
duced to  eat  about  6  ounces  (169.8  Gm.)  of  meat  in  each 
twenty-four  hours.  Beef  juice  and  the  concentrated  beef 
broths,  fresh  fruit,  together  wnth  watercress,  lettuce,  spinach, 
asparagus,  and  other  greens  help  to  vary  the  monotony  of  the 
beef  diet,  but  starchy  vegetables,  such  as  potatoes,  beets,  peas, 
and  corn  should  be  used  sparingly.  As  an  early  morning 
potion  designed  to  rid  the  gastric  mucosa  of  irritant  mucus 
and  to  free  the  bowels,  any  of  the  alkaline  laxative  waters  may 
be  used — effervescent  sodium  phosphate,  Rubinat,  Carlsbad 
Sprudel,  and  Hunyadi.  Alcohol  is  not  indicated,  although  it 
is  frequently  the  custom  to  allow  a  glass  of  claret,  Burgundy, 
or  stout  to  be  sipped  with  luncheon  or  dinner.  The  peculiar 
craving  for  acids,  so  commonly  a  complaint  of  the  chlorotic 
girl,  may  be  effectually  met  by  the  use  of  Ringer's  effervescent 
lemonade,  prepared  by  adding  to  half  a  pint  (240  mils)  of  iced 


CHLOKUSIS.  15 

water  the  juice  of  one  large  lemoiii,  sweetening-  with  a  lump  or 
two  of  sugar,  and  made  effervescent  by  the  addition  of  half 
a  teaspoonful  (1.9  mils)  of  sodium  bicarbonate. 

As  intimated  above,  there  are  many  imag^inary  complaints 
to  be  dealt  with.  In  the  average  case  of  chlorosis  symptoms 
that  demand  advice  rather  than  drug's,  are  the  source  of 
great  distress  to  the  patient.  In  such  instances,  counsel,  a 
cheery  outlook,  encouragement  about  fancied  ills,  go  a  long 
way  to  better  matters,  and  the  use  of  any  depressant  or  hyp- 
notic drugs  is  distinctly  bad  practice. 

Apart  from  these  functional  complaints,  there  are  certain 
symptom-groups  in  every  case  of  chlorosis  which  demand  ac- 
curate and  radical  therapeutic  measures.  One  must  be  on 
one's  guard  accurately  to  recognize  these  real  complaints,  and 
from  time  to  time  intelligently  to  relieve  such  symptoms, 
which  in  brief  may  be  referred  to  the  gastro-intestinal  tract, 
to  the  cardiovascular  apparatus,  and  to  the  nervous  system. 

Of  the  gastro-intestinal  symptoms,  constipation,  coated 
tongue,  flatulent  dyspepsia,  and  a  heavy  breath  are  the 
familiar  ills  complained  of;  peptic  ulcer  complicates  a  small 
percentage  of  cases ;  in  others  the  stomach  is,  abnormally  low 
and  dilated,  and  in  nearly  all  there  is  decided  impairment  of 
appetite,  if  not  a  complete  anorexia.  It  is  best  to  obviate 
constipation  by  urging  the  free  use  of  a  dietary  consisting 
largely  of  green  vegetables,  fruits,  salads,  and  fats.  When 
such  methods  require  to  be  supplemented,  enemata  are  in- 
dicated, and  if  this  also  fails  to  relieve  the  constipation,  small 
doses  of  cascara  sagrada,  phenolphthalein,  and  aloin  are  use- 
ful. Whatever  means  employed,  the  stools  should  be  kept  soft 
and  the  formation  of  scybillse  prevented.  If  hepatic  inaction 
and  inspissation  of  bile  exists,  a  course  of  acidum  sodium 
oleate  and  sodium  salicylate  usually  will'  cause  a  free  passage 
of  bile.  For  the  flatulent  dyspepsia  and  its  attendant  symp- 
toms, a  long  list  of  so-called  antifermentative  and  antiseptic 
medicaments  is  available.  The  following  will  be  found  to 
be  quite  as  useful  as  any  and  may  be  given  for  an  indefinite 
period  with  good  effects :  Taka-diastase,  pancreatin,  salol,  and 
extract  cascara  sagrada,  each  3  grains  (0.195  Gm.)  to  be  given 
at  mealtime.  For  a  gastric  indigestion  it  is  wise  to  use  a 
solution,  each  dram  of  which  contains  3  grains  (0.195  Gm.)  of 


16  DISEASES    OF    THE    BLOOD 

scale  pepsin  and  5  drops  (0.30  milj  of  dilute  hydrochloric  acid, 
this  to  be  given  in  2-dram  (8  milsj  doses,  well  diluted,  before 
meals;  this  combination  may  be  compounded  with  orange 
flower  water  and  glycerin  to  make  an  agreeable  mixture. 

Pick's  contention  holds  that  chlorosis  is  excited  by  a 
hemolysis,  due  to  toxin  generated  within  and  absorbed  from 
a  dilated  stomach.  However  this  may  be,  the  presence  of 
gastrectasis  demands  attention  in  a  considerable  proportion 
of  chlorotics,  and  this  complication  virtual!}'  demands  as  much 
attention  as  the  underlying  blood  defect.  A  gastrectatic 
dietary  is  indicated,  with  perhaps  the  use  of  the  stomach  tube 
and  the  administration  of  some  of  the  antifermentatives  just 
referred  to.  The  dietary  also  requires  most  careful  supervision 
in  such  cases,  and  on  this  point  it  will  be  sufficient  to  note  here 
that  concentrated  "dry"  foods  of  small  bulk  are  to  be  chosen 
rather  than  foods  which  overload  the  stomach  and  tend  to  re- 
main wnthin  the  stomach  for  a  protracted  period. 

In  cases  of  complicated  gastric  ulcer  Leube's  regime  or 
any  one  of  the  accepted  plans  of  routine  treatment  for  this 
condition  should  be  adopted,  and  such  drugs  as  bismuth, 
silver  nitrate,  and  opium  be  intelligently  prescribed.  (See 
Gastric  Ulcer.) 

Of  the  many  nervous  symptoms  inseparable  from  chlorosis, 
conditions  of  apathy,  mental  depression,  melancholia,  and 
hysteria  are  the  more  serious,  while  fretfulness,  unjust  criti- 
cism, petulance,  and  ill  temper,  demand  just  as  careful  atten- 
tion. These  symptoms  require  not  so  much  drugs  and  ner- 
vines as  they  do  firmness  and  suggestive  measures  on  the 
part  of  the  physician.  AMien  drugs  are  indispensable,  stron- 
tium bromid  and  the  isovalerianates  are  to  be  relied  upon 
rather  than  the  average  hypnotic.  Opiates  are  never  to  be 
used.  AA^hen  the  nen-ous  symptoms  consist  largely  of  tri- 
facial neuralgia  and  various  neuralgic  pains  elsewhere,  one  of 
the  less  depressant  coal-tar  analgesics  may  be  employed,  and 
for  this  purpose  acetphenetidin  combined  with  camphor  mono- 
bromate  and  salol  are  to  be  employed.  The  nervous  cough  so 
common  in  chlorosis  needs  no  special  treatment,  but  its 
presence  should  prompt  the  medical  attendant  to  identify 
it  merely  as  a  nerv^ous  bark  and  not  as  the  result  of  an  incip- 
ient phthisis. 


PERNICIOUS    ANEMIA.  17 

Cardiovascular  symptoms  which  are  purely  inorganic  in 
character  will  disappear  as  the  patient's  blood  improves. 
Meanwhile,  they  are  to  be  controlled  by  rest  and  the  ice-bag 
rather  than  by  the  use  of  any  of  the  so-called  cardiac  drugs. 

PERNICIOUS  ANEMIA. 

Pernicious  anemia  represents  a  form  of  fatal  blood  de- 
terioration depending  upon  a  reversion  on  the  part  of  the 
bone-marrow  to  an  embryonic  type  of  hemogenesis  and  char- 
acterized by  the  presence  in  the  circulating  blood  stream  of 
numerous  nucleated  erythrocytes,  conforming  histologically 
to  those  incident  to  fetal  life  (megaloblasts,  mesoblasts).  As- 
sociated with  the  foregoing  distinctive  retrograde  change, 
there  is  an  extreme  degree  of  hemoglobin  loss  and  even  a 
more  pronounced  decline  in  the  number  of  circulating  ery- 
throcytes— a  peculiarity  indicating  a  disproportionately  high 
content  of  hemoglobin  in  the  individual  red  corpuscles,  and 
referred  to  by  hematologists  as  a  condition  of  "high  color 
index."  Hand  in  hand  with  these  changes,  which  grow  pro- 
pressively  more  striking  as  the  disease  advances,  micro- 
chemical  alterations  and  stroma  degenerations  appear  in  many 
of  the  erythrocytes.  These  cells  lose  their  normal  bicon- 
cave, disc-like  contour,  and  even  coloring,  and  undergo  curious 
and  bizarre  distortions  of  size  and  shape  (poikilocytosis ; 
schistocytosis ;  microcytosis ;  megalocytosis)  ;  develop  baso- 
philic granulations  where  normally  the  stroma  stains  faintly 
acid  (granular  basophilia)  ;  and  show  diffuse  and  splotchy 
patches  of  basic  degeneration  in  the  cell  protoplasm  (poly- 
chromatophilia;  polychromasia). 

The  leucocytes  undergo  no  conspicuous  change,  although 
their  number  is  generally  diminished,  and,  differentially,  it 
is  found  that  a  relative  lymphocytosis  exists,  at  the  expense 
of  the  polymorphonuclear  neutrophiles,  whose  number  is  cor- 
respondingly diminished.  Small,  dwarf  myelocytes  commonly 
occur  in  small  percentages,  and  the  proportion  of  eosinophile 
leucocytes  is  subnormal. 

In  the  average  well  advanced  example  of  pernicious  anemia 
a  blood  examination  which  shows  a  hemoglobin  percentage 
below  20,  an  erythrocyte  count  in  the  neighborhood  of  1,000,- 

3 


18  DISEASES    OE    THE    BLOOD. 

000  cells  to  the  cubic  centimeter,  and  a  leucocyte  count  of  ap- 
proximately 1000  represents  the  degree  of  blood  impoverish- 
ment ordinarily  encountered. ^^ 

The  changes  in  the  bone-marrow  responsible  for  the  blood 
picture  reflect  an  effort  on  the  part  of  this  organ  to  compen- 
sate the  coexisting  blood  destruction.  They  consist,  in  brief, 
of  a  softening  and  hemorrhagic  condition  regarded,  not  as  a 
primary  causal  change,  but  as  a  secondary  lesion,  the  direct 
result  of  the  inroads  of  toxemia  and  hemolysis.  The  marrow 
loses  its  normal  yellowish  color,  becomes  red,  and  contains 
large  numbers  of  nucleated  erythrocytes  similar  to  those 
found  in  the  circulating  blood,  together  with  numerous  mye- 
logenous cells  so  hyaline  and  so  delicate  as  almost  to  escape 
detection. 

Aside  from  the  foregoing  alterations  in  the  bone-marrow, 
an  individual  dead  of  pernicious  anemia  shows  widespread 
evidences  of  a  fatal  hemolytic  anemia,  in  the  extensive  splenic 
and  hepatic  pigmentation,  and  in  the  excess  of  urinary  and 
fecal  blood-pigment  found  at  autoipsy.  The  pigmentation  of 
the  liver,  made  up  of  highly  ferruginous  material,  affects  par- 
ticularly the  cells  at  the  lobular  peripheries,  and  the  lymphatic 
endothelial  cells  and  capillaries.  Similar  proofs  of  hemolysis 
are  found  in  the  pigmented  and  enlarged  spleen,  in  which  vis- 
cus  the  pigment  granules  occur  both  in  the  vascular  walls  and 
are  disseminated,  intracellularly  and  free,  throughout  the 
structure  of  the  organ. 

Eppinger*^  believes  that  anatomic  changes  in  the  spleen  m 
pernicious  anemia  largely  accounts  for  the  excessive  erythro- 
cytic destruction  which  takes  place  in  this  organ,  the  exact 
site  of  the  hemolysis  being  the  splenic  pulp  which  the  ery- 
throcytes readily  permeate  owing  to  vascular  defects  peculiar 
to  this  form  of  anemia,  and  here  are  destroyed  in  large 
numbers.  This  author  describes  in  Addisonian  anemia  under 
the  term  "blood  lymph-nodes"  certain  structures  histologic- 
ally similar  to,  and  presumably  functionating  like,  the  splenic 
tissue.  In  subjects  not  benefited  by  removal  of  the  spleen 
{q.  V.  i.)  he  attributes  the  failure  to  the  fact  that  these  nodes 
carry  on  the  hemolytic  action  originally  exhibited  by  the 
spleen  before  operation.  Other  evidence  of  the  underlying 
hemolytic  factors  of  this  type  of  anemia  is  seen  in  the  undue 


PERXICIOUS    ANEMIA.  19 

amount  of  urobilin  found  in  the  stools,  and  as  shown  by  Scl- 
lards  and  Minot,'^  in  the  readiness  with  which  hemoglobinuria 
follows  the  subcutaneous  injection  of  solutions  of  hemoglol^in 
in  quantities  tolerated  by  other  forms  of  anemia  without  the 
appearance  of  this  blood  pig'ment  in  the  urine. 

Secondary  chang'es  affect  the  cardiovascular  system,  giving 
rise  in  some  instances  to  spontaneous  hemorrhages  and  to 
extreme  cardiac  debility;  and  the  liver  and  kidneys  are  prone 
to  suffer  similar  alterations. 

The  entire  alimentary  tract  is  commonly  affected,  oral 
sepsis,  septic  gastritis,  and  septic  enteritis  being  the  three 
most  frequent  lesions,  to  the  effects  of  which  W.  Hunter'^  is 
inclined  to  attribute  the  disease  under  discussion,  believing 
that  the  excessive  hemolysis  in  the  portal  area  is  directly  due 
to  the  action  of  an  unknown  specific  toxin  elaborated  in  the 
gastro-intestinal  canal.  Squier*^-  suggests  that  the  hemolysis 
may  be  referable  to  the  action  of  either  undigested  proteins  or 
putrefactive  poisons  wiiich  reach  the  blood  stream  through  a 
breach  in  the  mucosa  of  the  gastro-intestinal  tract.  In  the 
absence  of  definite  proof,  the  specific  action  of  this  unidentilied 
toxin  in  pernicious  anemia  can  be  accepted  only  upon  hypo- 
thetical grounds,  although  its  predisposing  action  is  easy  to 
credit. 

In  a  subject  constitutionally  susceptible  to  the  action  of 
blood-dissolving  agencies,  the  existence  of  a  profound  dis- 
turbance of  lipoid  metabolism  resulting  in  diminution  of  the 
antihemolytic  properties  of  the  whole  blood  may  prepare  the 
way  for  the  direct  action  of  the  hemolytic  substance,  especially 
if  this  defect  be  associated  with  disordered  functions  of  the 
ductless  glands.  In  this  speculation  as  to  the  identity  of  the 
toxin  responsible  for  Addisonian  anemia,  the  action  of  hemoly- 
tic toxins  in  other  grave  anemias  naturally  is  brought  to  mind, 
and  one  appreciates  a  comparable  condition  in  the  hemolytic 
anemias  referable  to  oleic  acid  in  Botlirioccphaiiis  infection,^ 
to  the  oxyphenylethylamin  poison  derived  from  the  Bacillus 
coli  communis,^^  to  absorption  through  a  pathologic  intestinal 
mucosa  of  foreign  protein, ^  to  the  poisonous  action  of 
oestrin,i2  and  to  the  placental  hemolytic  substance  active  in 
pregnant  women. 

The  spinal  cord  changes  are,  as  a  rule,  quite  conspicuous, 


20  DISEASES    OF    THE    BLOOD. 

and  consist  of  more  or  less  marked  sclerosis  of  the  posterior, 
lateral,  and  anterior  columns,  with  commonly  very  minute 
hemorrhagic  foci  distributed  through  the  substance  of  the  cord. 
Less  commonly,  degeneration  of  various  peripheral  nerve 
fibers  are  found,  as  a  consequence  of  neuritis. 

Here  ma}-  be  mentioned  a  rare  type  of  fatal  anemia,  known 
as  aplastic  anemia,  generally  regarded  as  a  form  of  pernicious 
anemia  in  wdiich  virtually  no  response  of  the  bone-marrow  to 
hemogenesis  exists.  Such  cases  run  a  rapidly  fatal  course, 
characterized  by  progressive  and  extreme  hemoglobin  and 
erythrocyte  losses,  a  low  color  index,  a  very  scanty  propor- 
tion of  erythroblasts,  or  none  at  all,  and  a  low  leucocyte  count, 
with  a  high  lymphocyte  percentage,  and  an  absence  of  mye- 
locytes. The  marrow  in  aplastic  anemia  is  in  a  state  of  hypo- 
plasia, or  indeed  it  may  be  actually  aplastic ;  contains  few,  if 
any,  marrow  cells ;  and  shows  either  a  yellowish  tint  or  is 
quite  colorless.  The  obvious  contrasting  features  of  the 
aplastic  variet}^  and  anemia  of  the  Addisonian  type  relate 
chiefly  to  the  pathology  of  the  bone-marrow  and  to  the  diiter- 
ences  in  the  blood  pictures — common  in  picturing  an  extreme 
anemia,  but  differing  essentially  bv  having  a  low  color  index 
and  absence  of  megaloblasts  in  the  former,  and  a  high  color 
index  and  a  predominance  of  megaloblasts  in  the  latter. 

TREATMENT. 

Intelligent  management  of  a  patient  affected  with  per- 
nicious anemia  includes  the  treatment  of  the  inherent  and  pro- 
gressive blood  deterioration,  and  the  care  of  the  distressing 
complications  of  the  underlying  hemolytic  process.  To  .the 
first  factor  are  referable  symptoms  such  as  dyspnea,  vertigo, 
syncope,  languor,  undue  prostration,  and  cardiac  disturbances. 
Physical  signs  like  mucosal  blanching,  pallor  and  lemon-yel- 
low tingeing  of  the  skin.,  scattered  small  subcutaneous  hemor- 
rhages, edema  of  the  ankles,  enlargement  of  the  liver  and 
spleen,  muscular  flabbiness  combined  with  apparent  preserva- 
tion of  body  fat,  and  a  soft,  full  pulse  with  tremulous  throb- 
bing of  the  superficial  vessels  complete  the  clinical  picture. 

In  numerous  instances  these  leading  clinical  featufes  are 
persistent,  and  intractable  indigestion,  obstinate  and  enfeeb- 


PERNICIOUS   ANEMIA.  ^1 

ling  attacks  of  diarrhea,  nausea,  and  vomiting-  cause  concern 
and  call  for  urgent  treatment.  The  mouth,  often  the  site  of 
disgusting  pyorrhea,  also  must  be  carefully  looked  after,  and 
other  focal  infections  eradicated.  In  this  endeavor,  a  thor- 
ough search  is  to  be  made  for  stomatitis,  adenoid,  tonsillar,  and 
dental  infections;  and  septic  lesions  of  the  stomach,  appendix, 
gall-bladder,  kidneys,  urinary  bladder,  and  uterus.  Surgical 
treatment  for  such  potential  factors  of  the  anemia  must  be 
decided  upon  so  soon  as  the  patient's  hemoglobin  approxi- 
mates 80  per  cent,  of  the  norrnal  standard,  and  sooner,  if  the 
blood  shows  no  definite  improvement,  apparently  because  of 
the  activity  of  the  area  of  focal  septic  absorption. 

Absolute  rest  in  bed  is  essential  for  the  satisfactory  treat- 
ment of  pernicious  anemia;  and  when  possible,  a  private  room 
in  the  hospital  with  a  special  nurse,  to  administer  to  the  pa- 
tient's most  trifling  needs,  should  be  engaged,  in  order  to  as- 
sure the  best  results  from  the  therapeutic  measures  employed. 
This  is  insisted  upon  by  Barker,63  who  also  advises  a  strict 
milk  diet,  especially  during  the  first  seven  days  of  confinement 
to  bed,  for  which  period  the  patient  receives  every  two  hours 
from  seven  a.m.  to  nine  p.m.  2V2  ounces  (75  mils)  of  milk  on 
the  first  day,i  the  two-hourly  amount  being  increased  each  day 
until  by  the  sixth  day  3  quarts  (liters)  are  given  in  each 
twenty-four  hours,  After  the  first  week^  the  strict  milk  diet  is 
substituted  by  a  ration  rich  in  protein,  fat,  and  carbohydrate, 
and  the  patient  is  urged  to  take,  in  addition  to  three  full  meals 
a  day,  several  raw  eggs,  a  quart  and  a  half  (iy2  liters)  of  milk 
and  one-half  pint  (236  mils)  of  cream  each  day. 

Arsenic,  for  almost  half  a  century  depended  upon  as  the 
most  powerful  single  agency  available  in  the  treatment  of 
pernicious  anemia,  has  not  been  replaced  by  any  more  effi- 
cacious drug  up  to  the  present  writing. 

In  the  last  few  years,  salvarsan  and  neosalvarsan,  contain- 
ing respectively  31.6  and  21.1  per  cent,  of  metallic  arsenic, 
have  been  used  to  some  extent  as  a  substitute  for  Fowler's 
solution,  on  the  whole  with  results  that  promise  their  con- 
tinued use  as  the  most  certain  form  of  therapy  in  this  disease. 

Salvarsan  may  be  given  intravenously,  exactly  as  it  is 
administered  in  syphilis,  but  in  smaller  doses  and  at  less  fre- 
quent intervals.     Boggs^^  advises  a  dose  of  0.3  g"rams  (4.6  gr.) 


22  DISEASES    OF    THE    BLOOD. 

once  every  four  weeks,  the  injections  l^eing  repeated  until  the 
blood  picture  reaches  an  approximately  normal  figure. 

Neosalvarsan  is  preferred  to  the  stronger  salt  by  Byron 
Bramwell,  who  introduced  the  arsenical  treatment  of  per- 
nicious anemia  in  1875,  on  the  premise  that  if  this  metal  is 
beneficial  in  fatty  heart,  it  also  might  be  of  use  in  this  grave 
form  of  anemia,  which  so  constantly  is  associated  with  such 
a  condition.  Neosalvarsan  is  administered  most  satisfactorih' 
I:))'  intramuscular  injections  of  from  0.3  to  0.6  grams  (4.6  to 
9.2  gr.),  repeated  at  the  same  intervals  adopted  in  giving  sal- 
varsan,  and  continued  until  similar  eft'ects  are  apparent.  Of 
the  two  drugs,  salvarsan  is  regarded  as  perhaps  the  more 
hazardous,  although  decidedly  more  rapid,  certain,  and  per- 
manent in  its  eft'ects,  and  apparently  is  peculiarly  indicated  in 
pernicious  anemias,  with  coincident  syphilis,  and  in  those 
wnth  a  pronounced  arsenic  idiosyncrasy.  In  favor  of  neo- 
salvarsan are  its  adaptability  to  subcutaneous  injection  with- 
out marked  local  inflammation ;  its  relatively  mild  systemic 
reaction — fever,  tachycardia,  vomiting,  anaphylactic  shock — 
and  the  sustained  and  continued  action  exerted  owing  to  its 
slow  absorption.  A  point  in  favor  of  both  salvarsan  and  neo- 
salvarsan is  their  slight  tendency  to  give  rise  to  peripheral 
neuritis  and  other  untoward  S3'mptoms  of  arsenical  intoler- 
ance, which  so  commonly  bar  the  continued  use  of  Fowler's 
solution  in  progressing  dosage. 

On  the  whole,  the  use  of  salvarsan  and  neosalvarsan  marks 
a  distinct  advance  over  the  older  arsenical  preparations  in  the 
treatment  of  Addisonian  anemias,  and  bids  fair  wholly  to  sup- 
plant the  routine  employment  of  Liquor  potassii  arsenitis, 
arsenous  acid,  and  sodium  cacodylate.  Bramwell  records^^ 
33.3  per  cent,  of  "temporary  complete  recoveries"  under  sal- 
varsan, in  contrast  to  12.7  per  cent,  under  Fowler's  solution ; 
the  number  of  cases  treated  being  110  in  the  first  group,  and 
21  in  the  second.  As  to  the  permanence  of  "cures,"  no  definite 
conclusion  is  warranted  until  the  treatment  has  endured  a 
more  convincing  test  of  time. 

Preparations  of  arsenic  other  than  salvarsan  still  enjoy 
considerable  vogue  in  certain  quarters,  and  merit  at  least 
parenthetic  mention,  in  case  the  use  of  the  newer  drug  be 
contraindicated  for  anv  reason.     Salvarsan   should  never  be 


PERNICIOUS   ANEMIA.  23 

given  in  the  face  of  renal  irritation,  and  should  be  used 
guardedly,  in  small  doses,  in  subjects  of  cardiac  weakness, 
striking-  asthenia,  gastric  irritability,  and  tendency  to  anaphy- 
lactic shock. 

If  circumstances  bar  the  use  of  salvarsan  or  neosalvarsan, 
one  must  be  content  to  resort  to  one  of  the  older  arsenic  prep- 
arations of  which  Fowler's  solution  is,  on  the  whole,  the  best 
tolerated  and  most  efficacious  in  the  great  majority  of  those 
who  are  forced  to  undergo  the  protracted  medicinal  use  of  this 
metal.  The  exact  point  of  tolerance  to  arsenic  varies  within 
wide  limits  in  the  individual  case ;  some  are  taken  with  ab- 
dominal pain  and  diarrhea  after  several  day's  administration 
of  but  a  few  drops  of  Fowler's  solution,  while  others  may  take 
without  discomfort  relatively  large  doses  for  weeks  at  a  time. 

In  dealing-  with  the  average  patient,  it  is  my  accustomed 
routine  to  administer  a  maximum  daily  dose  of  approximately 
30  minims  (2  mils)  of  Fowler's  solution  in  three  or  four  equal 
doses,  well  diluted,  and  taken  after  food.  The  initial  dose  is 
ordinarily  fixed  at  5  minims  (0.30  mil),  and  the  maximum 
amount  is  reached  by  gradually  increasing  the  dose  by  a  single 
minim  (0.06  mil),  say,  every  second  day.  Thus  the  fullest  pos- 
sible effect  of  the  drug  may  be  exhibited,  usually  with  no  risk 
of  the  gastric  and  renal  irritation  so  prone  to  be  excited  when 
arsenic  is  used  with  a  freer  hand  from  the  beginning.  Only 
in  the  more  fulminant  cases  of  pernicious  anemia  (and  these 
are  best  treated  by  some  other  methods)  should  one  risk  the 
by-efifects  of  a  more  vigorous  regime  with  the  drug  in  question. 
In  acute  exacerbations  of  Addisonian  anemia,  Chauffard's 
method  of  administering  Fowler's  solution  has  a  definite  place 
in  therapy.  This  author,  in  company  with  Laederich,  uses  a  1 
per  cent,  aqueous  solution  of  the  drug  with  1.33  per  cent, 
sodium  chlorid,  of  which  a  maximal  dosage  of  20  minims  (1.25 
mil)  are  given  hypodermically  each  day,  for  ten  consecutive 
days,  each  of  these  periods  of  treatment  being  separated  by  a 
week's  rest.  This  routine  has  been  followed  by  excellent  re- 
sults, and  is  reported  to  be  unproductive  of  arsenical  intoler- 
ance on  the  part  of  the  patient. 

Voga  and  McCurdyi^  are  strongly  in  favor  of  blood  trans- 
fusion as  a  promising  means  of  producing-  satisfactory  remis- 
sions of  considerable  duration.     Undertaken  at  an  early  stage 


24  DISEASES    OF    THE    BLOOD. 

of  the  disease,  the  transfusion  of  physiologically  unaltered 
blood  is  regarded  by  these  authors  as  a  palliative  treatment  of 
great  promise.  This  provided  that  the  technic  assures  the  use 
of  blood  proved  to  be  mutually  congenial  to  donor  and  re- 
cipient and  that  small  quantities  of  blood  are  introduced  at  in- 
tervals determined  chiefly  by  repeated  examinations  of  the 
patient's  blood  with  a  view  to  estimating  from  time  to  time  the 
regenerative  reaction  of  the  bone-marrow. 

The  intramuscular  injection  of  dehbrinated  blood  has  num- 
erous advocates  on  the  Continent,  and  recent  reports  credit 
the  procedure  with  freedom  from  systemic  ill-eftects,  and  with 
rapid  and  satisfactory  improvement  of  the  blood  picture  and  of 
the  patient's  general  health.  The  quantity-  of  blood  injected 
varies  from  20  mils  (5.4  fo)  used  as  an  original  minimum  dose, 
to  70  mils  (18.9  fo)  advised  as  the  maximum  quantity  by 
Zubryzcki.i*^  Ordinarily  the  number  of  injections  required  to 
bring  about  substantial  improvement  is  from  three  to  five, 
given  at  intervals  of  about  five  to  seven  days. 

The  injection  by  the  intravenous  route  of  not  more  than 
5  mils  (1.35  fo)  of  defibrinated  blood  is  advised  by  Weber^" 
as  a  method  of  treating  pernicious  anemia  followed  by  results 
comparable  to  those  obtained  with  arsenic.  He  cautions 
against  using  a  larger  amount  of  blood  than  the  quantity 
specified,  owing  to  the  likelihood  of  provoking  dangerous  re- 
actions and  because  of  the  better  therapeutic  effect  of  small 
doses. 

The  technic  followed  by  Archibald, ^^  of  the  ]\Iayo  Clinic, 
calls  for  from  one  to  four  transfusions  usually  of  500  mils 
(16.9  fo)  of  the  donor's  blood,  although  in  some  instances  good 
eflects  were  noted  with  much  smaller  quantities — 50  to  100 
mils  (1.69  to  3.38  f^).  In  this  series  of  25  cases  thus  treated  69 
per  cent,  were  immediately  benefited,  and  a  direct  relation- 
ship was  traced  between  the  procedure  and  the  subsequent  re- 
mission of  the  s^-mptoms.  Chronic  cases,  with  a  histor}-  of 
remissions,  appeared  most  likely  to  be  favorably  affected,  and 
those  unaft'ected  by  the  first  transfusion  frequently  responded 
when  a  dift'erent  donor  was  chosen  for  later  operations. 

Venesection  has  been  advised,  merely  as  a  palliative  meas- 
ure in  cases  resistant  to  the  usual  methods  of  treatment.  The 
temporary  benefit  thus  established  doubtless  depends  partly 


PERNMCIOUS    ANEMIA.  25 

Upon  a  stimulation  of  the  hemopoietic  tissues  and  to  some  ex- 
tent upon  the  withdrawal  of  the  blood  toxins  incident  to  the 
disease.  The  technic  does  not  differ  from  that  of  ordinary 
venesection,  the  blood  being  taken  from  a  vein  at  the  elbow. 
From  50  to  150  mils  (1.69  fg  to  5.07  fo)  are  withdrawn  at  each 
seance,  to  be  repeated  at  intervals  of  a  fortnight  during  a 
period  of  about  three  months.  In  most  instances  the  dual 
benefit  of  the  operation  is  shown  by  appreciable  improvement 
of  the  blood  picture  and  amelioration  of  the  evidences  of 
toxemia. 

The  treatment  of  pernicious  anemia  with  various  serums, 
notably  antidiphtheria,  antistreptococcus,  and  antistaphylo- 
coccus,  has  been  undertaken  on  the  basis  of  their  beneficial 
effect  in  the  high-grade  secondary  anemias,  and  on  such  a  pre- 
mise organotherapy  also  has  been  employed,  singly  and  com- 
bined. Thus  Bartolottiis  advises  in  cases  refractory  to  arsenic 
and  iron  therapy,  the  use  of  1000-unit  injections  of  antidiph- 
theria serum,  repeated  three  or  four  times  at  intervals  varying 
from  fourteen  to  forty  days,  in  combination  with  extract  of 
spleen  and  spinal  cord,  gradually  increased  from  0.5  gram 
(8  gr.)  to  2.75  grams  (38/^  gr.)  per  diem.  Under  this  routine 
one  of  Bartolotti's  patients  showed  normal  hemoglobin  and 
erythrocyte  figures  and  differential  leucocyte  count  six  months 
after  suspension  of  the  treatment.  In  this  connection  it  is  of 
interest  to  note  the  reputed  cures  of  a  number  of  cases  of  per- 
nicious anemia  reported  by  Mikhailoff,!^  who  resorted  to  the 
hypodermic  use  of  splenic  extract  alone,  in  doses  of  2.5  mils 
(40  m.)  of  a  2  per  cent,  solution.  In  one  patient  to  whom 
fifteen  such  treatments  were  given,  six  months  after  their  dis- 
continuance the  blood  was  normal  in  every  detail. 

The  use  of  antidiphtheria  serum,  of  obvious  utility  in  com- 
bating other  types  of  toxic  anemias,  has  a  certain  empiric 
place  in  the  therapeusis  of  Addisonian  anemias,  at  least  in 
those  examples  of  the  disease  in  which  the  toxemia  predomi- 
nates and  counteracts  the  attempts  to  better  the  blood  deter- 
ioration by  arsenical  treatment.  The  same  comment  appears 
to  be  justifiable  with  regard  to  the  use  of  splenic  extract  in  a 
similar  group  of  cases.  As  a  radical  cure,  however,  no  reports 
are  available  to  warrant  such  a  hope  from  either  serum  treat- 
ment or  organotherapy. 


26  DISEASES    OF    THE    BLOOD. 

Of  recent  years  splenectomy  has  become  recognized  as  a 
justifiable  surgical  procedure  in  selected  cases  of  pernicious 
anemia,  although  the  operation  should  be  undertaken  merely 
as  a  means  of  inducing  a  remission  usually  of  more  striking 
character  and  of  longer  duration  than  the  abatement  of  the 
active  symptoms  so  frequently  met  with  as  a  spontaneous 
change  or  as  one  due  to  active  arsenization  of  the  subject.  On 
the  basis  that  removal  of  the  spleen  is  often  followed  by  a  con- 
spicuous hemoglobin  and  erythrocyte  increase^o  by  signs  of 
hyperactivity  of  the  bone-marrow, 21  and  by  laboratory  find- 
ings indicating  diminished  hemolysis,^^  it  would  seem  rational 
to  interfere  surgically  as  a  curative  measure  in  this  disease. 
But  unfortunately  splenectomy  accomplishes  nothing  more 
tangible  than  temporary  improvement,  In  numerous  instances 
the  tenure  of  life  after  the  operation  has  been  measured  by 
years,  with  a  general  amelioration  of  the  most  distressing 
phases  of  the  illness.  In  the  recent  study  by  Krumbhaar--^  of 
the  exact  utility  of  the  operation,  the  details  relating  to  153 
cases  are  analyzed.  Of  27  cases  at  the  end  of  the  first  year 
after  operation,  9  were  dead,  7  had  relapsed,  and  11  had  im- 
proved ;  after  two  years,  the  figaires  read  one,  two,  and  three, 
respectively  for  the  6  patients  still  under  observation,  but  no 
radical  alteration  of  the  original  blood  picture  of  pernicious 
anemia  had  been  encountered.  The  immediate  post-operative 
mortality  of  splenectomy  in  subjects  of  pernicious  anemia  is 
approximately  20  per  cent.,  and  of  those  who  survive  the  oper- 
ation about  65  per  cent,  undergo  real  improvement  in  the 
blood  picture  and  in  the  general  clinical  features  of  the  affec- 
tion, no  appreciable  improvement  occurring  in  16  per  cent,  of 
the  second  group  of  cases.  The  post-operative  improvement 
was  generally  of  transient  nature,  and  likely  to  be  interrupted 
by  death  from  intercurrent  infection  or  a  fulminant  type  of 
relapse. 

Splenectomy  is  absolutely  contraindicated  in  the  aplastic 
forms  of  pernicious  anemia,  and  it  is  rarely  helpful  in  cases  in 
which  conspicuous  and  progressive  blood  deterioration  pre- 
dominates, and  in  those  with  active  symptoms  of  spinal  scle- 
rosis. The  procedure  is  of  service  in  middle-aged  or  young 
subjects  whose  blood  shows  regenerative  signs  (erythrocytic 
reticulation,    erythroblastic    crises,    HoweU-Jolly    bodies,    in- 


PERNICIOUS    ANEMIA.  27 

crease  of  platelets),  and  is  not  strikingly  below  the  (juantita- 
tive  and  qualitative  normal  standard,  and  whose  clinical  pic- 
ture, aside  from  the  diagnostic  blood-changes,  is  characterized 
by  a  reasonable  degree  of  hemolysis  and  by  moderate  splenic 
enlargement.  A  post-operative  laboratory  finding  of  real 
worth  is  the  diminished  urol^ilin  content  of  the  stools  in 
splenectomized  patients  to  which  evidence  of  lessened  hemo- 
lysis Eppinger-^  attaches  great  significance. 

When  combined  with  other  methods  of  therapy,  such  as 
full  arsenization,  radiation  is  to  be  regarded  as  helpful  in 
selected  examples  of  Addisonian  anemia,  but  neither  in  com- 
bination— much  less  alone — can  it  be  relied  upon  to  accom- 
plish a  radical  cure  for  this  affection. 

Exposure  to  the  Rontg'en  ray  improves  some  cases  of  per- 
nicious anemia,  but  quite  fails  to  influence  others,  and  no 
real  curative  influence  can  be  attributed  to  this  form  of  treat- 
ment. It  is  particularly  those  instances  in  which  the  bone- 
marrow  degeneration  has  not  progressed  to  a  point  where 
this  tissue  fails  to  respond  to  stimulation  in  which  radiation 
is  helpful,  and  in  such  cases  the  improvement  may  be  prompt 
and  striking,  although  unfortunately,  not  lasting  in  those 
treated  with  A'-ray  alone,  unsupported  by  other  measures. 

The  same  technic  as  that  used  in  leukemia  (q.v.)  is  satis- 
factory in  pernicious  anemia,  and  the  progress  of  the  treat- 
ment should  be  followed  by'  the  results  of  repeated  blood 
examinations,  which  show  an  increase  in  the  number  of  ery- 
throblasts  in  patients  undergoing  improvement,  but  no  such 
evidence  of  blood  regeneration  in  those  whose  marrow  is  un- 
influenced by  the  rays. 

Of  the  various  special  symptoms  which  may  demand  atten- 
tion in  the  subject  of  pernicious  anemia,  the  gastro-intestinal 
disturbances  are  by  all  odds  the  most  common  and  trouble- 
some to  manage.  Acute  gastro-enteric  manifestations  in- 
stinctively call  to  the  physician's  mind  arsenic  intolerance  as 
the  exciting  cause,  and  with  equal  meaning  the  subject  of  the 
patient's  dietary.  The  simple  test  of  withholding  arsenic  for 
a  time,  together  with  a  strict  revision  of  the  diet,  will 
settle  the  question  as  to  whether  the  disturbances  were  due 
to  such  factors  as  these.  If  this  does  not  better  matters,  a 
more  definite  method  is  to  be  adopted.     In  this  connection  it 


28  DISEASES    OF    THE   BLOOD. 

must  be  recalled  that  the  care  of  the  mouth  is  to  receive  atten- 
tion; dental  caries  is  to  be  treated;  and  ulcerated  ^ums  must 
be  healed  before  one  can  believe  that  all  factors  of  gastro- 
intestinal sj-mptoms  are  eliminated. 

Manjr  cases  of  pernicious  anemia  are  subject  to  capillar}^ 
hemorrhages,  and  this  sort  of  bleeding  usually  can  be  con- 
trolled readily  by  the  various  hemostatic  drugs.  Oozing  from 
the  mouth  or  nose  is  best  treated  by  the  topical  application  of 
adrenalin  chlorid  in  1 :  1000  solution,  of  fluidextract  of  hama- 
^ehs,  or  of  gljcerite  of  alum;  the  use  also  of  coagulin  (Ciba.) 
is  applicable  in  this  t3^pe  of  bleeding.  Packing  the  nares 
with  sterile  gauze  strips,  soaked  with  1 :  2000  adrenalin  chlorid 
solution,  will  usually  immediately  control  a  troublesome  nose- 
bleed. If  there  be  retinal  hemorrhage,  it  is  advisable  to  use 
one  of  the  iodids,  preferably  sodium  iodid,  in  doses  of  from  15 
to  30  grains  (1  to  2  Gm.)  daily  to  favor  absorption  of  the  clot. 

Intestinal  bleeding  calls  for  temporary  withdrawal  of  all 
food  by  the  mouth.  Iced  compresses  to  the  abdomen,  the 
insistence  of  rest  in  bed,  and  the  use  of  appropriate  styptics, 
which  act  upon  the  mucous  surface  of  the  bowel  are  useful  in 
this  emergency.  A  favorite  pill  for  this  purpose  is  composed 
of  1  grain  (0.065  Gm.)  lead  acetate,  2  grains  (0.130  Gm.)  of 
camphor,  and  %  grain  (0.016  Gm.)  of  opium.  Monsel's  solu- 
tion of  subsulphate  of  iron  is  another  drug  much  used  in  intes- 
tinal bleeding;  it  should  be  administered  in  3-grain  (0.195 
Gm.)  salol-coated  pills,  to  insure  its  reaching  the  intestinal 
canal  undissolved.  In  order  to  control  a  hemorrhage  in  the 
lower  bowel  the  foUovdng  rectal  injection  will  prove  useful: 
enemas  of  iced  water;  of  2  per  cent,  alum  solution;  of  2  per 
cer.t.  tannic  acid;  of  5  per  cent.  Monsel's  solution;  of  %  per 
cent,  silver  nitrate ;  of  J/2  per  cent  argyTol.  Hematemesis, 
which  is  a  most  unusual  symptom,  does  occasionally  occur, 
and  is  a  source  of  great  alarm  to  the  patient,  even  if  it  does 
not  endanger  his  life.  For  this  accident  an  ice-bag  to  the  epi- 
gastrium, and  the  use  of  astringents,  such  as  Monsel's  solu- 
tion, silver  nitrate,  tannin,  and  adrenalin  are  indicated ;  and  the 
pill  mentioned  above  of  lead,  camphor,  and  opium  may  be 
given;  rectal  feeding  should  of  course  be  substituted  for 
feeding  by  the  mouth.  The  methods  just  noted  are  better 
adapted  to  control  hematemesis  than  the  use  of  sulphuric  acid 


LEUKEMIA.  29 

or  of  turpentine,  formerly  much  employed  for  this  purpose. 
Sensory  disturbances,  such  as  lightning-like  pains  in  the  ex- 
tremities, like  those  of  tabes,  are  a  leading  symptom  in  many 
cases  of  Addisonian  anemia.  For  these  disturbances  the  nar- 
cotics never  should  be  used  except  in  the  case  of  an  acute 
emergency.  It  is  much  better  to  apply  a  snugly  fitting  flan- 
nel bandage,  with  rest  and  elevation  of  the  painful  limb,  and 
to  massage  the  parts  with  some  anodyne  rubefacient  such  as 
methyl  oleosalicylate. 

LEUKEMIA. 

Leukemia  as  a  clinical  entity  bears  many  of  the  hall-marks 
of  an  infectious  process,  affecting  selectively  the  bone-mar- 
row, the  spleen,  and  the  h-mphatic  apparatus  of  the  body.  In 
the  more  active  varieties  of  the  affection  are  those  similarities 
to  an  infection  the  more  conspicuous,  as  evidenced  by  the 
prominence  of  hyperpyrexia,  profound  asthenia,  spontaneous 
hemorrhages,  and  splenomegaly  as  prominent  clinical  features 
of  such  examples  of  the  leukemic  process.  As  to  the  exact 
nature  of  the  infectious  principle  at  work,  there  is  no  avail- 
able information.  It  may  be  some  unidentified  specific  micro- 
organism, or  it  may  be  a  multiple  infection ;  at  all  events,  the 
process,  whatever  its  real  character,  is  generally  characterized 
by  a  clinical  course  of  well-marked  chronicity,  likely  to  be- 
come interrupted  from  time  to  time  by  acute  exacerbations 
which  sooner  or  later  prove  fatal.  Other  cases  lack  this 
chronic  character,  and  exhibit  from  the  first  an  active  violence 
of  the  clinical  picture  which  resists  all  the  efforts  for  improve- 
ment at  least  temporarily  eilective  in  the  leukemias  of  less 
fulminant  type. 

Here  may  be  mentioned  the  inherent  tendency  of  leukemic 
blood  suddenly  to  undergo  an  aleukemic  transformation  under 
the  influence  of  some  one  of  the  intercurrent  infections,  such 
as  pneumonia  and  diphtheria.  The  apparentl)-  close  interrela- 
tionship between  various  infections,  and  the  appearance  of 
relatively  large  numbers  of  myelocytes  in  the  circulating 
blood,  gives  further  food  for  thoug'ht  on  the  question  of  leu- 
kemia's infectious  nature ;  and  the  same  comment  applies  to 
the  seemingly  selective  action  of  tonsillar  and  intestinal  infec- 
tions upon  the  myelogenous  tissues. 


30  DISEASES    OF   THE   BLOOD. 

With  this  idea  in  mind,  it  is  still  possible,  for  the  sake 
of  convenience,  to  designate  by  the  predominant  features  of 
the  blood  picture  two  different  types  of  leukemia,  the  mye- 
logenous and  the  lymphatic,  and  further  to  speak  of  two  wholly 
artificial  clinical  varieties  of  the  disease,  the  acute  and  the 
chronic.  It  is  sufficient  here  to  state  that  of  these  forms  of 
the  disease  the  mj^elogenous  is  more  likely  to  follow  a  more 
chronic  course  than  the  lymphatic,  and  that,  as  a  rule,  it  is 
more  radically  affected  by  therapeutic  measures,  which  unfor- 


Fig.  1. — Leukemic  enlargement  of  the  spleen.     (From  Da  Costa's 
Physical  Diagnosis.     Copyright,  W.  B.  Saunders  Co.) 

tunately  promise  little  more  than  a  temporary  amelioration  of 
the  symptoms  in  either  form  of  the  disease. 

In  the  management  of  a  case  of  leukemia,  irrespective  of 
its  exact  clinical  variety,  there  are  several  distinct  lines  of 
treatment  to  be  followed,  dealing  with  the  blood  picture,  with 
the  general  symptom-complex,  and  with  special  individual 
symptoms  of  the  leukemic  state. 

The  hlood  picture  in  all  forms  of  the  disease  is  alike,  in  that 
it  is  characterized  by  an  excessive  number  of  leucocytes  in  the 
circulating  blood,  and  by  a  hemoglobin  deficiency  and  loss  of 


LEUKEMIA.  31 

erythrocytes,  which  frc(|uently  accounts  for  an  anemia  of  the 
most  extreme  grade. 

The  differences  in  the  blood  pictures  of  the  two  clinical 
varieties  of  leukemia  may  be  briefly  summarized  by  asso- 
ciating with  the  myelogenous  type  the  blood  changes  known 
as  myclcmia  and  with  the  lymphatic  type  those  referred  to  by 
the  term  lymphemia. 

In  myclcmia  the  leucocyte  increase  is  made  up  predomi- 
nantly of  myelocytes,  which  constitute  approximately  one- 
fifth  of  the  total  number  of  leucocytes,  ordinarily  forty  or  fifty 
times  higher  than  the  accepted  normal  count. 

The  myelocytes,  which  are  regarded  as  the  immediate  pre- 
cursors of  the  normal  polynuclear  neutrophiles,  are  the  pro- 
duct of  an  imperfect  and  overstimulated  hematopoiesis,  by 
fault  of  which  the  bone-marrow  produces  large  numbers  of 
these  immature  cells  of  variable  size,  with  a  single  eccentric 
non-convoluted  nucleus  deficient  in  chromatin  network,  and 
a  protoplasm  crowded  with  delicate  neutrophile  granules.  In 
health,  such  cells,  as  they  age,  gradually  diminish  in  size, 
acquire  a  denser  nuclear  structure,  and  show  an  increase  in 
the  number  of  protoplasmic  granules  whose  neutrophilic  re- 
action persists  unchanged,  until  finally  they  become  trans- 
formed into  normal  polynuclear  neutrophiles. 

The  metachromatic  mast  cells  also  are  very  numerous  in 
the  myelogenous  type,  the  eosinophilic  leucocytes  (both  poly- 
morphonuclear and  myelocytic)  occur  in  abundance,  while 
widespread  degenerative  changes  affecting  the  protoplasm  and 
the  nuclei  of  all  the  white  corpuscles  are  conspicuous  features 
of  the  stained  specimen. 

In  lymphemia  the  high  leucocyte  count  is  due  to  a  dispro- 
portionately excessive  number  of  lymphocytes,  which,  as  a 
rule,  constitute  more  than  nine-tenths  of  the  different  varieties 
of  leucocytes.  In  the  more  chronic  lymphatic  leukemias,  the 
small  lymphocyte  generally  is  the  prevailing  type  of  this  cell 
encountered,  whereas  in  the  acute  forms  of  the  disease  the 
larger  varieties  of  lymphocyte  predominate.  Myelocytes  are 
present  in  fractional  percentages  in  lymphemic  blood,  and  the 
same  is  true  of  mast  cells  and  of  eosinophilic  leucocytes. 

Aside  from  the  essential  leucocyte  proliferation  of  leu- 
kemia, the  associated  anemia  is  an  important  detail  of  the  dis- 


32  DISEASES    OF   THE   BLOOD. 

ease,  and  in  some  instances  this  feature  is  so  conspicuous  as 
to  deserve  quite  as  careful  management  as  the  underlying  leu- 
kemic process.  Other  conditions  being  equal,  the  more  acute 
the  type  of  leukemia  the  more  severe  the  attendant  hemo- 
globin and  erythrocyte  losses,  and  the  greater  their  tendency 
to  conform  to  a  progressive,  pernicious  type. 

In  contrast  to  the  more  moderate  grade  of  anemia  com- 
monly found  in  chronic  myelogenous  leukemia,  the  blood 
deterioration  in  acute  lymphatic  leukemia  is  likely  to  reach 
an  extreme  grade,  and  to  show,  in  consequence  of  the  modi- 
fied embr}'onic  blood  manufacture,  numerous  erythroc3'tes  of 
the  fetal  type,  designated  as  megaloblasts  and  mesoblasts,  to- 
gether with  many  nucleated  er\"throcytes,  termed  normo- 
blasts, also  met  with  in  other  severe  anemic  conditions.  The 
leucocyte  count  tends  to  remain  at  a  lower  level  than  is  the 
rule  in  myelogenous  cases. 

In  both  forms  of  leukemia  the  effect  upon  the  leukemic 
blood  picture  of  complications  such  as  hemorrhage,  diarrhea, 
and  intercurrent  infections  should  be  recalled ;  the  first-named 
conditions  provoking  an  exaggerated  hemoglobin  and  erytiiro- 
cyte  loss  with  polymorphonuclear  neurophile  leucocytosis ; 
the  second,  a  moderate  and  transient  improvement  of  the 
anemia  due  to  blood  concentration,  and  the  last  a  temporar}^ 
subsidence  of  the  original  leukemic  blood  findings. 

TREATMENT. 

So  long  as  the  attendant  anemia  does  not  progress  acutely, 
the  leucocyte  count  is  not  subject  to  violent  exacerbations, 
and  the  splenomegaly  remains  within  reasonable  limits,  it  is 
questionable  whether  any  form  of  active  treatment  should  be 
instituted  in  a  patient  affected  with  chronic  leukemia,  either 
of  the  myelogenous  or  the  lymphatic  variety.  This  tem- 
porizing attitude  is  prompted  by  the  tendency  of  this  disease 
suddenly  and  without  warning  to  suiter  violent  relapses  just 
at  a  time  when  a  permanent  cure  is  looked  for — relapses  which 
carry  the  blood  deterioration  far  below  the  level  originally 
determined ;  and  which  have  proved  rapidly  fatal  in  not  a  few 
instances. 

^Mth    this    unfortunate    peculiarity    in    view,    the    physi- 


LEUKEMIA.  33 

cian  proceeds  with  those  measures  aimed  to  overcome 
the  three  chief  existing  morl:)id  processes  of  the  average  leu- 
kemic subject:  the  active  output  of  pathologic  leukocytes,  the 
huge  splenic,  hepatic,  and  lymphatic  tumors,  and  the  severe 
progressive  loss  of  hemoglobin  and  erythrocytes.  For  the 
correction  of  these  symptoms,  present  practice  allows  the 
choice,  singly  or  in  combination,  of  radiation  with  the  Ront- 
gen  ray,  the  administration  of  benzol,,  and  the  judicious  use  of 
hematinics,  such  as  iron  and  arsenic,  supplemented  by  a  gen- 
erous dietary  of  nitrogenous  meats,  and  various  ferruginous 
foods.  Further  details  of  the  case  management  are  discussed 
after  the  consideration  of  these  therapeutic  ventures. 

In  chronic  myelogenous,  and,  with  less  certainty,  in  lym- 
phatic leukemia,  the  therapeutic  use  of  the  Rontgen  ray  has 
become  an  established  means  of  controlling  the  hyperactivities 
of  the  leukopoietic  tissues,  and  of  destroying  the  excess  of 
circulating  leucocytes.  But  against  its  advantages  the  clini- 
cian must  weigh  certain  disadvantages  inherent  to  the  .ir-ray, 
since  to  overradiation  may  be  a.ttributed  distressing  skin 
burns  and  also  a  fatal  type  of  leucocytotoxemia,  while  under- 
radiation  occasionally  provokes  a  stimulation  of  leucocyte 
production  by  fault  of  which  the  leukemic  process  flares  up 
in  an  astonishing  manner.  To  protect  the  patient  from  the 
first  of  these  unfortunate  by-efifects,  the  repeated  exposure  of 
the  same  part  of  the  body  should  be  avoided,  by  mapping  out 
the  surface  over  the  spleen,  the  long  bones,  and  the  superficial 
lymphatic  glands  into  a  number  of  exposure  areas  upon  which 
the  .^--rays  are  focussed  in  rotation  according  to  a  prearranged 
plan.  It  is  also  customary  to  make  use  of  a  covering  of  lead 
plaster  or  of  sheet  silver  as  a  protective  shield  to  filter  out 
the  irritant  and  therapeutically  inert  rays  without  interfering 
with  the  action  of  the  curative  rays.  Barring  the  ever-present 
personal  equation,  and  controlled  by  frequently  repeated 
blood  examinations,  radiations  of  five,  ten,  or  twenty  minutes' 
duration,  varying  from  one  seance  each  day  to  one  weekly,  will 
be  found  satisfactory  in  most  instances. 

Whatever  be  the  routine  adopted,  radiation  should  not  be 
pushed  too  rapidly  for  fear  of  exciting  a  reaction  which  may 
fatally  intensify  the  leukemic  process,  and  safety  demands 
initial  exposures  of  brief  duration  at  infrequent  intervals — 


"34  DISEASES    OF    THE   BLOOD. 

details  obviously  to  be  determined  by  the  peculiarities  of  the 
individual  case. 

Fever,  symptoms  of  acute  intoxication,  the  development  ol 
additional  leukemia  tumors,  prostration,  cachexia,  and  anemia 
characterized  by  extreme  oligocythemia  and  numerous  megalo- 
blasts  forbid  the  use  of  the  Rontgen  ray.  Renal  complications 
do  not  absolutely  contraindicate  this  form  of  therapy,  but  are 
a  danger  signal  to  pursue  it  with  exceeding  caution. 

To  sum  up  the  utility  of  radiotherapy,  it  may  be  regarded 
.  as  a  means  of  arresting  a  large  proportion  of  early  cases  of 
myelogenous  leukemia,  and  of  improving  the  blood  picture 
and  clinical  symptoms  of  many  advanced  ones.  In  acute  leu- 
kemia little  benefit  can  be  anticipated  from  this  or  from  any 
other  form  of  treatment,  and  in  such  instances  arsenic  and 
thorium-.ar  {q.v.)  offer  more  hope  of  prolonged  life.  Lym- 
phatic leukemia  is  less  susceptible  to  ,t--ray  therapy  than  the 
myelogenous  variety,  and  recurrences,  so  common  in  both,  are 
more  frequent  and  more  fulminant  in  the  former.  Warthin's 
studies^s  demonstrate  the  pathologic  basis  of  the  foregoing 
statement,  and  prove  that  the  action  of  the  .r-rays,  although 
it  modifies  the  leukemic  process  by  exciting  inhibitive  degen- 
eration, leaves  the  essential  leukemic  lesions  to  progress  vir- 
tually unchecked.  Indeed  the  leucopoietic  tissues  may  sufifer 
complete  destruction,  with  a  resultant  aleukemic  condition  of 
the  blood,  and,  after  a  lapse  of  time,  with  the  growth  of  con- 
siderable undifferentiated  leukoblastic  tissues,  and  perhaps  a 
consequent  return  of  the  leukemic  blood  changes.  Sympto- 
matic cures  have  been  reported,  some  of  several  years'  stand- 
ing,,, but  on  the  whole  one  must  not  regard  radiothei-apy  as 
specific,  although  it  fills  an  indispensable  place  in  a  selected 
class  of  cases. 

Under  such  a  regimen,  carried  on  for  ten  days  or  a  fort- 
night, the  high  leucocyte  count  tends  to  fall  normalward,  and 
the  pathologic  varieties  of  cells  to  diminish ;  simultaneously  or 
shortly  afterward  the  enlarged  spleen  and  liver  become 
smaller,  and  the  palpable  lymphatic  glands  soften.  Very  sig- 
nificant histologic  changes  in  the  cells  of  the  circulating  blood 
include  nuclear  swelling  and  chromatin  fragmentation  affect- 
ing the  lymphocytes,  the  polymorphonuclear  neutrophiles,  and 
their     pathologic     marrow     antecedents,     the     myelocytes. 


LEUKEMIA.  35 

Finally,  the  protoplasm  of  the  j^ranuiar  cells  become  studded 
with  vacuoles  and  devoid  of  tyrannies,  and  in  successful  cases 
the  myelocytes  and  mast  cells  disappear  from  the  perij^heral 
circulation.  Definite  improvement  in  the  hemoglol)in  per- 
centage and  the  erythrocyte  count  later  appears,  to  complete 
the  histologic  evidence  of  the  blood  regeneration  thus  in- 
duced by  rontgenization. 

Benzol  must  be  used  with  caution,  for  its  action  is  that  of 
a  leucocytotoxic  agent;  and  in  an  overdose  in  a  susceptible 
subject  it  may  provoke  intense  renal  inflammation,  free 
hemorrhages,  extreme  anemia,  and  striking  leucopenia.  The 
drug's  activities  are  essentially  those  of  the  impure  benzene 
of  commerce,  and  are  directed  primarily  upon  the  leukoblastic 
tissues,  whose  functional  activity  in  both  normal  and  abnor- 
mal states  is  markedly  diminished.  Von  Koranyi,^^  who 
suggested  this  form  of  hemotherapy,  based  his  idea  of  its 
clinical  application  on  Telling's  report,  in  1910,  of  his  experi- 
ments to  demonstrate  the  leucocytotoxic  action  of  the  drug. 
The  pioneer  work  thus  begun  was  soon  supplemented  by 
other  Continental  clinicians,  notably  by  Kiralfi^'^'  and  in 
America  by  Billings.^s 

In  the  favorable  case  benzol  causes  a  moderate  prelim- 
inary rise  in  the  number  of  leucocytes,  followed  by  a  striking 
diminution  of  their  number,  particularly  affecting  the  poly- 
morphonuclear neutrophils.  The  pathologic  types  of  leuco- 
cytes more  or  less  rapidly  diminish,  and  as  the  myelocytes, 
mast  cellsy  and  other  distinctively  leukemic  cells  disappear,  a 
virtually  normal  different  leucocyte  count  is  approached. 
Coincidentally  there  is  usually  a  moderate,  sometimes  decided, 
hemoglobin  and  erythrocyte  fall,  although  but  rarely  does  the 
associated  anemia  demand  suspension  of  the  treatment.  As  a 
rule,  these  blood  changes  are  attended  by  a  decided  improve- 
ment of  the  patient's  health  and  strength,  and  by  rapid  dimi- 
nution of  the  size  of  the  spleen  and  liver,  with  less  conspicuous 
disappearance  of  the  enlarged  lymphatics. 

The  ill-advised  use  of  the  drug  results  in  a  total  atrophy 
and  destruction  of  the  hemogenetic  organs,  total  loss  of  coag- 
ulation, and  an  aleukemic  blood  picture  associated  with  a 
high-grade  anemia. 

From   this   it  would   appear   that  benzol,   despite   its   real 


36  DISEASES    OF    THE    BLOOD. 

value  in  the  symptomatic  cure  of  the  leukemias,  must  be  re- 
garded as  a  powerful  leucocytic  poison,  possessed  of  a  toxic 
action  which  when  once  excited  cannot  be  neutralized.  An- 
other drawback  to  its  indiscriminate  use  is  its  variable  activi- 
ties in  different  individuals,  a  defect  to  be  explained  chiefly 
on  the  ground  of  great  differences  in  personal  susceptibility  to 
its  action. 

Gastric  disturbances,  headache,  vertigo,  bladder  irritabil- 
ity, progressive  anemia,  and  urine  changes  indicative  of  renal 
•irritation  should  be  regarded  as  signs  for  the  immediate 
withdrawal  of  the  drug,  the  action  of  which,  it  should 
be  noted,  tends  to  persist  for  some  time  after  its  use  has  been 
discontinued.  These  unto'ward  effects  of  benzol,  according  to 
the  consensus  of  opinion,  are  more-  likely  to  appear  in  walking 
patients  than  in  those  confined  to  bed  during  its  administra- 
tion ;  hence  its  use  is  safer  in  the  hospital  ward  than  with  out- 
patients. 

The  most  successful  method  of  administerins:  benzol  is 
in  freshly  hlled  gelatin  capsules,  wnth  an  equal  quantity  of 
pure  olive  oil,  the  initial  daily  dose  of  the  drug  being  30 
grains  (2  Gms.),  with  45  grains  (3  Gms.)  the  second  day,  60 
grains  (4  Gms.  i  the  third  day,  and  75  grains  (5  Gms.)  the 
fourth  day,  this  maximum  dose  of  5  grams  being  continued 
each  day.  provided  that  no  ill-effects  arise,  until  the  leucocyte 
count  has  fallen  approximately  to  as  low  as  20,000  cells  per 
cubic  millimeter. 

On  the  whole,  benzol,  if  used  intelligently  in  carefully 
selected  cases,  offers  more  rapid  and  more  certain  effects  than 
any  other  means  at  the  internist's  disposal  in  the  management 
of  the  chronic  leukemias.  It  should  quite  replace  the  huge 
doses  of  Fowler's  solution  of  arsenic  formerly  given ;  it  is 
certainly  more  effective  than  salvarsan ;  and  not  only  more 
efficacious  but  cheaper  and  less  elaborate  than  the  employ- 
ment of  the  Rontgen  ray,  useful  as  may  be  the  last-named 
when  skilfully  applied. 

This  fact  must  be  emphasized :  that  benzol,  contrary-  to 
first  impressions,  cannot  be  looked  upon  as  a  radical  cure  for 
leukemia.  The  most  that  can  be  hoped  for,  despite  the 
dramatic  disappearance  of  the  leukemic  blood  picture  and  the 
subject's  obviously  bettered  condition,  is  a  temporary  remis- 


LEUKEMIA.  37 

sion  of  the  symptom-complex,  which,  unless  a  prolonged  ben- 
zol therapy  is  persisted  in,  results  at  best  in  a  lease  of  life 
measured  more  commonly  by  months  than  by  years.  Pushed 
too  far,  benzol  produces  a  fatal  breakdown  of  the  blood- 
forming  organs,  and,  on  the  other  hand,  too  moderate  a  dose 
results  in  violent  stimulation  of  the  leucoblastic  tissues,  and 
only  exaggerates  the  leukemic  process.  Patients  do  better  on 
a  treatment  of  benzol  combined  with  .t'-ray  therapy  than  on 
benzol  alone. 

Thorium-x,  which  possesses  radioactive  properties,  has 
been  used  to  some  extent  to  control  the  abnormal  leucocytic 
output  of  leukemia,  owing  to  its  pronounced  selective  action 
on  the  leucocytes  in  this  disease.  This  action  is  similar  to 
that  exerted  by  intense  radiation  with  the  ;r-ray,  and  to  that 
produced  by  radium  emanations.  The  metal  is  usually  ad- 
ministered internally,-  at  intervals  of  two  or  three  days,  in 
doses  of  from  75  to  150  electrostatic  units,  until  its  efifects 
{v.i.)  are  apparent;  or  a  single  intravenous  injection  of  5000 
units  may  be  given,  although  this  is  more  risky  and  may  set 
up  an  extreme  erythrocytic  destruction.'^^  In  the  limited 
number  of  instances  in  which  the  thorium  salt  has  been  used; 
satisfactory  leucopenia,  improvement  of  the  different  leuco- 
cyte count,  diminution  of  the  splenohepatic  tumors,  and  soft- 
ening of  the  lymphatic  enlargements  have  promptly  followed, 
although  at  the  present  writing  the  permanence  of  these 
changes  cannot  be  unequivocally  attested. 

In  favor  of  the  thorium  treatment  are  its  harmlessness 
under  intelligent  administration,  its  exact  and  graduated  dos- 
age^ and,  as  contrasted  to  treatment  by  intense  radiation,  the 
avoidance  of  injury  to  the  skin  from  .I'-ray  burns.  J\Iost  of 
the  reported  thorium  "cures"  have  been  in  cases  treated  ap- 
parently without  success  with  the  Rontgen  ray,  hence  con- 
fusion must  exist  as  to  the  real  benefit  derived.  This,  however, 
■should  be  conceded :  thorium  seems  to  supplement  the  good 
effects  of  radiation,  and  the  two  methods  of  treatment  may  be 
tried  in  combination  to  effect  the  sought-for  permanent  leuco- 
cyte decline. 

Arsenic,  formerly  quite  generally  in  vogue  for  its  reputed 
curative  properties  in  leukemia,  has  been  abandoned  in  its 
■former  role,  but  still  is  of  distinct  utility  in  combating  the 


38  DISEASES    OF   THE   BLOOD. 

concomitant  anemia,  and  as  a  substitute  for,  or  an  accom- 
paniment of,  radiation  and  the  newer  drugs,  benzol  and 
thorium. 

Arsenic  is  indicated  in  patients  who,  after  a  comprehen- 
sive course  of  one  of  these  therapeutic  measures,  either  fail 
to  improve,  grow  distinctly  worse,  or  exhibit  a  distressing 
intolerance.  In  such  instances  it  is  sometimes  possible  to 
discontinue  the  plan  of  treatment  first  pursued,  and  to  sub- 
stitute in  its  place  a  vigorous  course  of  arsenic,  which  later 
•may  or  ma}-  not  be  combined  with  the  original  treatment,  as 
circumstances  determine  the  wisdom  of  such  action.  It  is 
also  customary  to  resort  to  arsenic  as  a  post-leukemia  regimen 
in  cases  symptomatically  free  from  the  disease,  and  to  use 
this  drug  freely  in  examples  of  the  aleukemic  condition  in- 
duced by  intensive  treatment  by  other  methods.  Fowler's 
solution  (Liquor  potassii  arsenitis),  if  no  personal  hypersuscep- 
tibilitv  exists,  can  be  relied  upon  for  prolonged  administration 
and  in  leukemic  cases  it  acts  quite  as  well  as  the  more  expen- 
sive salvarsan  and  sodium  cacodylate.  The  initial  doses,  3  to  5 
minims  (0.18  to  0.30  mil)  daily,  should  be  pushed  by  increas- 
ing 1  minim  (0.06  mil)  over  the  preceding  dose  on  alternate 
'da3^s  until  a  daily  intake  of  approximately  15  or  20  minims 
(0.92  or  1.25  mils)  is  attained,  at  which  dose  it  should  be  con- 
■  tinned  for  an  indefinite  period.  The  old  method  calling  for 
amazingly  large  doses  of  arsenic  is  now  known  to  be  a  harmful 
routine  for  the  leukemic  subject,  and  has  been  abandoned  for 
conservative  blood  building  without  risk  of  arsenic  poisoning. 
Should  Fowler's  solution  in  adequate  dosage  prove  intolerable, 
it  is  sound  therapy  to  employ  arv'larsonates,  of  which  atoxyl  is 
one  of  the  most  useful  preparations.  Administered  hypoder- 
mically,  in  daily  doses  of  from  ^  to  1  grain  (0.032  to  0.065 
Gm.),  the  drug  should  be  given  for  three  consecutive  weeks, 
and  the  injections  suspended  the  fourth  week;  by  this  method 
the  hematinic  action  of  the  salt  is  actively  enlisted,  without 
fear  of  toxic  effects  either  direct  or  cumulative. 

Those  who  have  used  atoxyl  intelligently  are  struck  with 
its  inefficacy  after  an  initial  improvement  of  the  blood 
picture,  which,  as  a  rule,  consists  of  a  moderate,  although 
distinct,  decline  in  the  num.ber  of  leucocytes  and  percentage 
of  myelocytes  and  mast  cells.    When  this  point  is  reached  (and 


LEUKEMIA.  39 

unfortunately  it  is  a  point  far  short  of  the  normal  level j,  con- 
tinuance of  atoxyl  does  no  good  whatever,  nor  do  toxic  evi- 
dences of  arsenic  supervene. 

If  sodium  cacodylate  be  chosen,  this  arsenic  salt  should  be 
used  by  intramuscular  injection  in  doses  of  2  grains  (0.13  Gm.) 
three  times  weekly. 

To  counteract  the  extreme  hemoglobin  deficiency  existing 
in  leukemic  subjects,  the  persistent  and  free  use  of  iron  is 
called  for,  to  supplement  the  more  dramatic  results  achieved  by 
one  of  the  leucocytotoxic  agencies.  Recalling  that  this  grave 
blood  disorder  is  inherently  a  form  of  myeloid  hyperplasia 
closely  related  to,  if  not  actually  part  and  parcel  of,  a  malig- 
nant infection,  the  essential  importance  of  this  metal  in  an 
endeavor  to  combat  the  associated  anemia  is  apparent.  Three 
principal  factors  are  accountable  for  this  high-grade  leukemic 
anemia:  faulty  hematopoiesis,  attributable  to  the  leukemic 
bone-marrow  lesions ;  hemolysis  excited  by  the  inroads  of  the 
circulating  toxins ;  and  interference  with  food  absorption  and 
assimilation.  Factors  such  as  these  adequately  explain  the 
presence  of  leukemic  anemias,  always  of  high  grade,  and  fre- 
quently tending  to  become  characterized  by  the  histologic 
hall-marks  of  a  grave  type  of  essential  blood  deterioration. 

As  a  rule  the  hemoglobin  deficiency  in  leukemia  is  much 
more  decided  in  the  lymphatic  type  than  in  the  myelogenous, 
and,  irrespective  of  the  type  of  the  diseases,  tends  to  be  more 
decided  in  acute  than  in  chronic  cases.  The  most  conspicuous 
feature  of  a  leukemic  anemia  is  the  prevalence  of  normoblasts 
and  in  the  acute  forms  of  the  disease  the  tendency  of  the  ery- 
throcytes to  undergo  structural  changes  of  a  most  pronounced 
nature,  which  in  some  instances  at  least  reminds  one  more 
than  superficially  of  the  blood  picture  incident  to  true  Addi- 
sonian anemia. 

So  long  as  the  iron  salt  chosen  is  well  tolerated  and  efifi- 
cient,  it  matters  but  little  what  form  of  iron  is  given  to  abate 
the  leukemic  anemia.  Inasmuch  as  in  sfivino-  iron  to  the 
average  leukemic  patient  means  a  long  siege  of  treatment,  the 
endeavor  must  be  made  to  use  one  of  the  less  irritant  forms 
of  the  metal,  and  one  in  which  confidence  may  be  placed  for 
the  consistent  improvement  of  a  deficient  hemoglobin  percent- 
age.    The  iron  carbonate  recommended  for  the  treatment  of 


40  DISEASES    OF    THE    BLOOD. 

chlorosis,  citrate  of  iron,  and  ferratin  all  may  be  taken  for 
some  length  of  time  without  unfavorable  effects,  and  all  are 
satisfactory  hematinics. 

The  intramuscular  injection  of  defibrinated  blood  has  been 
suggested  as  rational  therapy  in  leukemia,  but  the  procedure 
has  not  been  carried  out  with  favorable  results,  save  in 
isolated  instances.  Kiralfi-^  advises  such  treatment  espe- 
cially in  leukemias  in  which,  after  a  course  of  radiation  and 
benzol,  the  initial  improvement  has  been  succeeded  by  ex- 
.treme  leucopenia  and  grave  anemia.  In  such  cases  the  injec- 
tion of  10  mils  (2.7  fo)  of  fresh  human  blood  into  the  gluteal 
muscle  apparently  causes  a  fall  of  the  leucocyte  count  to  the 
mean  normal  maximum  and  by  a  definite  improvement  in  the 
hemoglobin  and  erythrocyte  figures.  Pari  passu  with  the  bet- 
terment of  the  blood  picture  the  other  clinical  features  tend 
slowly  to  improve,  but  not,  so  far  as  can  be  determined,  to 
the  point  of  an  actual  cure  of  the  leukemic  condition.  The 
intramuscular  injection  of  blood,  it  would  seem,  is  called  for, 
not  as  a  factor  of  eradicating  the  underlying  leukemic  process, 
but  rather  as  a  means  of  controlling  the  acute  leucocytolytic 
fiarebacks  which  so  frequently  attend  the  active  use  of  the 
Rontgen  ray  or  benzol  therapy. 

Aside  from  the  foregoing  more  or  less  accepted  methods 
of  treatment,  the  therapeusis  of  leukemia,  in  common  with 
other  incurable  maladies,  entails  the  trial  of  a  long  list  of 
reputed  remedial  measures,  none  of  which  can  be  regarded  as 
permanently  helpful. 

Thus  the  injection  of  bacterial  toxins  has  been  largely  ad- 
vocated, on  the  premise  that  leukemic  processes  are  frequently 
interrupted  and  temporarily  held  in  abeyance  by  various  inter- 
current infections.  Larrabee,^^  arguing  that  the  deliberate 
injection  of  bacterial  toxins  should  have  a  similar  effect, 
treated  several  cases  with  Coley's  fluid  (Streptococcus 
prodigiosus  toxins),  with  equivocal  results;  and  Baldauf,^! 
reports  fair  success  with  the  use  of  bacterial  toxins  in  myelo- 
genous, but  not  in  lymphatic,  types  of  the  disease. 

Tuberculin  injections  in  the  treatment  of  leukemia  have 
been  attended  by  little  or  no  permanent  improvement,  possibly 
because,  as  Dock^s  suggests,  tuberculosis  complicating  a  leu- 
kemic process  has  no  effect  in  modifying  the  latter,  such  as  an 


LEUKEMIA.  4l 

interctirrent  streptococcemia  does.  Alien  leukemic  serum  has 
been  tried  by  Capps/^"^  splenic  extract  by  Jacobs,'^'-*  formalin 
by  Baily,^^  and  cinnamic  acid  by  Richter,-^"^'  all  with  disap- 
pointing results  in  so  far  as  the  actual  control  of  the  leukemic 
process  is  concerned. 

Splenectomy,  despite  its  utility  in  splenic  anemia,  and  in 
some  examples  of  Addisonian  anemia,  is  emphatically  contra- 
indicated  in  leukemic  subjects.  The  futility  of  this  operative 
procedure  in  all  types  of  this  grave  blood  disorder  is  well  ex- 
pressed by  von  Leube,-'*'^  who  insists  that  "the  time  has  come 
to  discontinue  all  efforts  to  cure  the  disease  by  injections 
into  the  spleen,  by  faradization  or  galvanopuncture 
of  the  organ,,  by  extirpation  of  the  glands  or  by  splenectomy." 

Of  the  numerous  special  symptoms  which  are  prone  to  com- 
plicate a  leukemic  condition,  gastro-intestinal  disturbances, 
cardiac  disorders,  and  various  forms  of  dropsy  are  conspicuous 
examples,  and  often  are  present  in  such  a  striking  and  stub- 
born form  as  to  defy  all  attempts  for  their  amelioration. 

Of  the  gastro-intestinal  disturbances,  obstinate  diarrhea  is 
a  prominent  symptom,  and  one  frequently  most  difficult 
to  control.  It  arises  from  leucocytic  infiltration  of  the  intes- 
tine, swelling  of  the  lymphoid  follicles,  and  in  some  cases 
ulceration  of  the  wall  of  the  gut,  which  lesions  cannot  be 
expected  to  yield  to  the  measures  used  for  the  control  of  an 
ordinary  simple  intestinal  catarrh.  These  complications,  de- 
pending,! as  they  do,  upon  the  underlying  leucocytic  process, 
may  be  treated  with  a  view  to  the  emergencies  they  provoke. 
Opium  in  full  doses,  for  example,  and  frequent  irrigation  of  the 
bowel  with  enemas  of  iced  water,  of  alum  (2  per  cent.)  of 
tannic  acid  (2  per  cent.),  of  Monsel's  solution  (5  per  cent.),  of 
argyrol  (0.5  per  cent.),  are  useful  for  the  control  of  the  diar- 
rhea; or  albuminate  of  tannin  in  15-grain  (1  Gm.)  doses,  and 
a  pill  containing  1  grain .  (0.65  Gm.)  lead  acetate,  2  grains 
(0.130  Gm.)  camphor,  and  ^  grain  (0.016  Gm.)  opium,  is  use- 
ful as  a  supplementary  measure  for  the  same  purpose.  Rest 
in  bed,  restriction  of  the  diet,  and  the  use  of  lactobacillary 
products  with  pancreatin,  diastase,  and  pepsin-  are  helpful 
measures,  though  not  per  se  curative.  Loss  of  appetite, 
nausea,  vomiting,  and  other  purely  gastric  symptoms,  are  to 
be  treated  along  general  lines. 


42  DISEASES    OF   THE   BLOOD. 

Cardiac  disturbances  more  commonly  are  attributable  to 
the  pressure  of  the  huge  splenic  tumor  than  to  organic  lesions 
of  the  heart's  musculature  or  endocardium.  If  due  to  the 
splenomegaly,  the  use  of  a  bed-rest,  to  afford  a  semi-recum- 
bent posture,  and  the  habitual  avoidance  of  the  dorsal  de- 
cubitus bv  the  patient,  will  go  far  to  relieve  the  discomfort. 
If  perisplenitis  co-exists,  as  not  infrequentl}-  is  the  case,  these 
mechanical  measures  may  have  to  be  supplemented  by  the 
use  of  some  form  of  opium,  and  by  the  application  of  adhesive 
strips  adjusted  so  as  to  support  the  splenic  enlargement  and 
to  limit  the  respiratorv  excursions  of  the  lower  left  thorax. 

In  the  presence  of  an  actual  cardiac  lesion,  which  if  it 
exists,  commonly  consists  of  fatty  changes  in  the  musculature, 
strychnin,  digitalis,  and  strophanthus  are  capable  of  much 
good,  if  used  according  to  definite  indications.  Syncope  and 
paroxysms  of  dyspnea,  most  common  complicating  symp- 
toms, usuallv  are  promptly  relieved  by  some  one  of  the 
dili'use  stimulants  such  as.  for  example.  Holtmann's  anodyne, 
spirits  of  camphor,  or  aromatic  spirits  of  ammonia. 

Dropsy  is  a  familiar  objective  symptom  in  leukemia,  and 
arises  from  various  factors,  which  must  be  clearly  identified 
in  order  to  proceed  intelligently  with  the  treatment. 

Anemic  dropsy  is  by  all  odds  the  most  frequent  type 
encountered,  and  of  this  sort  of  edema  bogginess  of  the 
patient's  legs  and  ankles  is  the  chief  symptom.  This  can  be 
greatly  relieved  by  the  firm  application  of  a  flannel  bandage, 
and,  naturally,  by  pursuance  of  the  measures  originally  planned 
to  combat  the  leukemic  anemia. 

The  edema  consequent  to  the  venous  obstruction  caused 
by  the  pressure  of  the  splenic  mass  is  relieved  by  the  use  of 
a  flannel  binder  fitted  to  the  belly,  from  pubis  to  xiphoid,  so 
as  to  aftord  firm  support  with  upward  oblique  traction.  In 
splenomegalic  dropsy  one  must  also  insist  on  the  postural 
rules  recounted  above  (z'.s.).  Hydragogue  cathartics,  owing 
to  their  irritant  eltect  upon  the  already  diarrheal  bowel,  should 
not  be  employed  to  relieve  the  abdomen  of  a  fluid  mass,  nor  is 
it  safe  to  aspirate  the  ascites. 

Cardiac  dropsy,  an  uncommon  complication,  calls  for  treat- 
ment directed  toward  strengthening  the  tonicity  and  contrac- 
tile force  of  the  myocardium,  therapeutic  measures  that  have 
been  considered  elsewhere.     (See  ^Myocarditis.) 


CHLOROMA.  43 

Spontaneous  hemorrhages  are  common,  especially  in  the 
lymphatic  variety  of  the  disease,  but,  as  a  rule,  the  bleeding  is 
not  a  serious  incident,  and  can  be  controlled  by  simple 
methods,  such  as  firm  pressure  and  the  local  application  of 
styptics.  Commonly  the  accident  amounts  merely  to  epis- 
taxis,  or  bleeding  from  the^gum;  rarely,  the  hemorrhage  is 
renal,  pulmonary,  or  cerebral ;  and  exceptionally,  it  is  in  the 
form  of  a  cachectic  purpura  or  larger  extravasations,  partic- 
ularly in  acute  forms  of  leukemia.  The  treatment  of  the  vari- 
ous factors  of  the  hemorrhages  just  mentioned  is  given  under 
the  appropriate  headings.     (See  page  52,  et  seq.) 

Finally,  apart  from  all  routine  courses  of  therapy,  origin- 
ally designed  to  overcome  the  essential  leukemic  disorder,  the 
patient  must  be  enjoined  to  rest,  to  live  in  the  open  air  and 
sunshine,  and  to  partake  of  a  full  and  nutritious  diet,  in  an 
effort  thus  to  postpone  the  period  of  bedridden  helplessness 
which  ultimately  must  come  in  every  case.  When  this  occurs 
the  palliative  measures,,  at  first  mercifully  helpful,  prove  of  no 
avail  whatever,  and  one  must  resort  to  the  judicious  use  of 
opiates,  to  deaden  the  effects  of  the  leukemic  inroads  and  to 
tranquilize  the  sufferer's  last  days.  In  acute  leukemia  the 
average  tenure  of  life,  from  the  onset  of  the  initial  S3^mptoms, 
may  be  not  longer  than  a  few  weeks ;  in  chronic  cases,  it  is  ap- 
proximately three  years,  and  sometimes  longer. 

CHLOROMA. 

Chloroma  is  to  be  regarded  as  a  morbid  transitional  lesion 
betAveen  true  leukemia  and  malignant  neoplasms,  as  signified 
by  its  synonymous  terms,  green  cancer  and  chlorosarcoma. 

Pathologically,  this  disease  is  characterized  by  neoplastic 
growths  of  greenish  color  implicating  especially  the  orbits, 
temporal  fossae,  and  vertebrae;  and  by  marrow  changes  simi- 
lar to  those  of  myelogenous  leukemia.  The  blood  picture  is 
inconstant,  but,  as  a  rule,  it  typifies  lymphemia,  with  large 
hyaline  mononuclear  cells  in  excess ;  or  the  myeloid  type  of 
blood  may  prevail. 

The  treatment  of  chloroma  can  be  but  palliative,  for  the 
disease  Invariably  runs  a  rapidly  fatal  course,  lasting  not 
longer  than  six  months,  in  the  average  case. 


44  DISEASES    OF   THE   BLOOD. 

The  T-ray  may  afford  a  temporary  amelioration  of  the 
symptoms,  and  the  vigorous  use  of  iron  and  arsenic  occasion- 
ally is  of  similar  service,  but  no  therapeutic  measures  avail  in 
permanently  controlling  the  widespread  chloromatous  infiltra- 
tion, once  its  invasion  of  the  subject's  adenoid,  visceral,  and 
osseous  structures  is  excited. 

HODGKIN'S  DISEASE. 

Hodgkin's  disease,  also  known  as  pseudoleukemia  and 
lymphadenoma,  is  a  condition  of  obscure  origin  and  unknown 
etiology,  featured  clinically  by  progressive  enlargement  of  the 


.  Fig.  2. — Generalized  glandular  enlargement  in  Hodgkin's  dis- 
ease. (From  Da  Costa's  Physical  Diagnosis.  Copyright,  W.  B. 
Saunders  Co.) 

lymphatic  glands  and  usually  of  the  spleen  in  association  with 
an  anemia  of  variable  degree.  As  a  rule,  the  actual  blood 
picture  is  but  little  altered,  but  in  some  cases  the  deterioration 
is  excessive.  The  glands  commonly  affected  are  those  of  the 
neck.  Appearing  in  this  site,  or  perhaps  in  the  glands  of  the 
axilla  or  of  the  groin,  the  diagnosis  may  be  more  readily  made 
than  when  the  condition  arises  in  the  retroperitoneal  glands 
or  in  the  peribronchial  lymphatic  structures ;  under  the  latter 
circumstances  the  diagnosis  ordinarily  is  made  at  autopsy. 
Hodgkin's  disease  is  to  be  differentiated  from  other  conditions 
which   produce    enlargement   of   the   lymphatic    glands,    first 


HOIJGKIN'S    D1SE7\SE.  45 

among  which  is  tuberculous  adenitis,  while  other  conditions 
demanding  careful  differentiation  are  lymphosarcoma,  lymphocar- 
cinoma,  and  chronic  leukemia.  In  Hodgkin's  disease  the  en- 
largements are  usually  discrete,  and  the  glands  rarely  tend  to 
soften,  coalesce,  suppurate,  and  fistulate,  as  is  the  common 
course  of  a  tuberculous  adenitis.  Hodgkin's  disease  is  pro- 
g'ressive  in  course,  while  tuberculous  adenitis  may  r&main 
quite  stationary  and  is  continued  over  a  longer  period  of  time. 
Lymphosarcoma,  on  the  other  hand,  extends  much  more 
rapidly  than  either  of  these  lesions,  and  soon  implicates  sur- 
rounding tissues  en  masse.  Carcinoma  of  the  lymphatic  glands 
is  associated  with  the  cachexia  and  pain  so  often  characteristic 
of  cancer  elsewhere  in  the  body.  Chronic  leukemia,  of  course, 
presents  a  profoundly  altered  blood  picture.  Hodgkin's  dis- 
ease may  be  characterized  by  an  irregular  fever.  Should  the 
glandular  enlargements  be  of  such  size  as  to  press  on  sur- 
rounding structures,  pressure  symptoms  ensue ;  decided  swell- 
ing of  the  arm  may  result  from  this  cause,  as  also  may 
dyspnea,  gastro-intes-tinal  symptoms,  and  syndromes  refer- 
able to  the  nervous  system.  Bronzing  of  the  skin  may  appear 
when  the  abdominal  glands  are  invaded,  and  a  purpuric  rash 
may  be  present  at  times. 

The  blood,  while  appearing  thin  and  pale,  does  not  show 
much  departure  from  the  normal  picture.  The  erythrocytes 
may  be  slightly  diminished  in  number,  and  the  leucocytes 
rarely  are  above  the  normal  maximum  limit  of  10,000 ;  the 
hemoglobin  is,  however,  reduced  15  or  20  per  cent.  The  dis- 
ease would  seem  to  be  more  common  in  males,  judging  from 
Gower's  studies  of  100  cases,  which  showed  that  75  men  were 
affected  to  25  women.  The  prognosis  is  extremely  grave. 
The  average  duration  of  life  after  the  condition  is  diagnosed 
has  been  placed  at  two  years — a  statement  which,  of  course,  is 
modified  by  the  previous  condition,  life,  and  history  of  the 
patient,  and  by  the  response  of  the  individual  to  treatment. 

TREATMENT.  ' 

The  first  step  in  treatment  is  to  arrive  conclusively  at  the 
correct  diagnosis  of  Hodgkin's  disease  by  the  exclusion  of  a 
possible  tuberculous  glandular  enlargement.  If  information  in 
this  regard  cannot  be  obtained  from  tuberculin  reactions,  such 


46  DISEASES    OF    THE    BLOOD. 

as  the  von  Pirquet  test,  it  is  quite  permissible  to  excise  a 
small  portion  of  a  gland  for  histologic  study.  Hodgkin's  dis- 
ease often  yields  temporarily  to  the  use  of  arsenic,  such  as 
Fowler's  solution,  in  gradually  increasing  dose,  until  perhaps 
15  or  20  minims  (1  to  1.3  mil)  have  been  reached,  or  until  the 
physiologic  tolerance  of  the  drug  is  exhibited  by  a  metallic 
taste  in  the  mouth,  by  puffiness  under  the  lower  eyelids,  or 
by  the  onset  of  gastro-intestinal  symptoms  of  moderate  de- 
gree. Of  late,  arsenic  in  the  form  of  salvarsan  injections  has 
"been  happily  emplo3^ed.  Following  such  intravenous  injec- 
tion, the  glands  have  been  observed  to  shrink  and  harden,  the 
temperature  to  drop,  and  the  patient's  general  condition  to 
improve.  Sooner  or  later,  however,  the  symptoms  will  recur, 
and  subsequent  injections  are  not  accompanied  by  the  gratify- 
ing results  which  follow  the  first  administration  of  salvarsan. 

X-ray  therapy,  administered  at  the  hands  of  a  competent 
operator,  is  always  to  be  thought  of  and  tried.  When  pain- 
ful or  urgent  symptoms  arise  as  a  result  of  glandular  pressure, 
operative  interference  is,  of  course,  indicated  to  relieve  the 
discomfort. 

To  a  limited  extent  vaccine  therapy  enjoys  a  certain  vogue 
in  the  treatment  of  Hodgkin's  disease,  but,  unfortunately, 
without  either  curative  or  even  palliative  effect,  to  judge  from 
the  moderate  number  of  cases  available  for  study.  Even 
autogenous  diphtheroid  vaccines,  such  as  used  by  Smoot  and 
Carrell,^"^^  apparently  prove  futile,  for  their  use  is  followed 
merely  by  a  temporary  decrease  in  the  size  of  the  enlarged 
glands,  with  no  permanent  improvement  of  the  local  lesions 
or  of  the  constitutional  symptoms. 

The  treatment  of  Hodgkin's  disease  by  the  injection  of 
tuberculin  seems  wholly  empiric  and  unjustified.  This  means 
of  therapy  is  based  upon  nothing  more  tangible  than  the  fact 
that  the  coincidence  of  tuberculosis  and  pseudoleukemia  in  the 
same  individual  may  modify  the  latter  process. 

The  surgical  treatment  of  Hodgkin's  disease  is  warmly  ad- 
vocated by  Yates  and  Bunting,66  who,  assuming  the  part 
played  by  infection,  urge  as  a  preliminary  step  the  thorough 
elimination  of  ail  portals  of  entry  for  invading  bacteria,  by 
attention  to  inflamed  tonsils  and  infected  teeth  and  accessory 
sinuses.    This  accomplished,  radical  extirpation  of  all  diseased 


SPLENIC   ANEMIA.  47 

lymphoid  tissue  within  reach  of  the  knife  is  done,  and  this  is 
followed  by  systematic  radiation  and  by  the  use  of  immune 
serum.  These  authors  consider  this  routine  exceedingly  useful, 
believing  that  it  is  curative  in  fully  20  per  cent,  of  all  cases. 

Admitting  the  possible  relationship  of  Hodgkin's  disease 
and  sarcoma,  it  is  but  natural  to  urge  the  adoption  of  identical 
surgical  measures  in  both  conditions,  at  least  in  the  former's  in- 
cipiency,  at  a  time  when  a  single  gland  is  affected  or  when  the 
adenopathies  have  not  progressed  far.  The  operation  should 
be  radical,  and,  as  Coley^^  points  out,  must  include  enucleation 
of  the  tonsils,  if  these  glands,  the  probable  seat  of  the  primary 
infection,  also  are  enlarg-ed.  Of  Coley's  series  of  22  cases,40 
treated  variously  by  surgery,  ^--rays,  and  bacterial  toxins,  13 
died,  2  showed  no  improvement,  4  definitely  grew  better,  and 
3  were  lost  sight  of. 

The  use  of  an  immune  serum  prepared  with  the  Bacillus 
hodgkini  is  advised,  on  the  basis  of  the  specificity  of  this  germ, 
and  in  subjects  thus  treated  a  fall  of  temperature,  lessening 
of  the  glandular  swellings,  and  improvement  of  the  subjective 
symptoms  have  been  observed  by  several  investigators. 

The  general  condition  of  the  patient  should  be  appro- 
priately treated.  Tonics,  to  support  the  failing  strength  may 
be  required,  among  which  iron,  quinin,  and  strychnin  may  be 
advantageously  used.  Codliver  oil  or  other  emulsified  fats 
may  be  prescribed  with  good  efifects.  The  use  of  antipyretics 
is  rarely  justified,  the  fever  being  better  combated  by  the  use 
of  tepid  baths  and  similar  harmless  measures.  The  condition 
of  the  intestinal  canal,  which  may  be  readily  upset  by  torpor 
of  the  liver,  will  require  attention.  Anorexia  and  nausea 
call  for  the  exhibition  of  simple  digestants.  For  the  profound 
prostration  and  symptoms  of  myocardial  degeneration  digitalis 
in  supportive  doses  is  necessary. 

SPLENIC  ANEMIA. 

An  excellent  description  of  the  disorder  under  discussion  is 
expressed  by  the  words  of  Sir  William  Osier:  "Provisionally, 
it  is  useful  to  group  together  cases  of  idiopathic  enlargement 
of  the  spleen  with  anemia  without  lymphatic  involvement,  and 
to  label  the  condition  splenic  anemia."^i    This  grouping  fur- 


48  DISEASES    OF    THE    BLOOD. 

nishes  a  fairly  definite  working  basis  for  the  investigation  of 
the  loose  term,  splenic  anemia,  from  a  clinical  viewpoint,  but 
it  does  not  indicate  the  dominant  pathologic  peculiarities  of  the 
various  types  of  the  aftection.  It  excludes  the  splenic  enlarge- 
ments so  common  in  malaria,  tuberculosis,  syphilis,  secondary 
anemia,  and  those  incident  to  leukemia,  Hodgkin's  disease, 
pernicious  anemia,  and  tropical  splenomegaly.  It  includes  cer- 
tain anemic  splenomegalies  of  peculiar  character,  the  three 
principal  varieties  of  which  are  designated  as  Banti's  disease, 
splenomegaly  of  the  Gaucher  type,  and  von  Jaksch's  splenic 
anemia  of  infancy. 

The  chief  pathologic  changes  of  adult  splenic  anemia  re- 
late to  enlargement  of  the  spleen,  and  to  secondary  cir- 
rhosis of  the  liver.  To  a  less  conspicuous  extent  there  are, 
more  or  less  constantly,  definite  changes  affecting  the  gastro- 
intestinal tract,  the  portal  circulation,  and  the  bone-marrow. 

In  the  ordinary  type  of  splenic  anemia  the  splenic  enlarge- 
ment is  referable  to  a  generalized  fibrosis  and  hyperplasia 
shared  in  common  by  the  reticulum,  capsule,  and  malpighian 
bodies,  in  which  process  proliferation  of  the  blood  sinus  endo- 
thelial cells  is  an  important  detail.  By  some  investigators  this 
endothelial  proliferation  is  considered  the  characteristic  path- 
ologic change,  and  one  accounting  for  the  elaboration  of  a 
hemolytic  toxin  to  which  the  coincident  anemia  is  directly  due. 
Associated  with  these  changes,  moderate  fibrosis  of  the  portal 
areas  of  the  liver,  thrombosis  of  the  portal  vein,  and  enlarge- 
ment of  the  hemolymph  glands  are  conspicuous,  but  incon- 
stant, secondar}^  lesions.  The  bone-marrow  undergoes  no 
distinctive  alteration ;  the  lymphatic  glands  are  unaffected. 

In  certain  cases  of  splenic  anemia,  the  complete  syndrome 
of  anemia,  splenomegaly,  hepatic  cirrhosis,  and  ascites  develops 
as  a  terminal  stage,  and  to  this  group  the  term  Banti's  disease 
is  applied.  The  liver,  after  a  temporary  increase  in  its 
size,  corresponding  to  the  acute  stage  of  the  disease,  under- 
goes cirrhosis  greatly  resembling  that  of  the  alcoholic  t3^pe  of 
Laennec,  and  from  this  factor  ascites  arises.  The  alterations 
in  the  bone-marrow  vary  in  different  cases  of  Banti's  disease, 
lymphoid  degeneration,  erythroblastic  increase,  and  the  pres- 
ence of  phagocyted  ers^throcytes  and  blood  pigment  being  the 
most  frequent  changes  observed. 


SPLENIC   ANEMIA.  49 

In  the  gastro-intestinal  tract,  general  atrophy  of  the  in- 
testinal mucosa,  circumscribed  thickening  of  the  intestinal 
wall,  and  esophageal  and  hemorrhoidal  varices  are  the  lesions 
whose  incidence  is  fairly  constant. 

Splenomegaly  of  the  Gaucher  type  represents  a  clinical 
entity,  characterized  by  histologic  changes  wholly  different 
from  those  already  described  in  the  other  varieties  of  splenic 
anemia,  with  which  it  is  grouped,  more  for  convenience  sake 
than  upon  a  sound  pathologic  basis.  In  Gaucher's  disease  the 
splenic  enlargement  is  directly  due  to  an  accumulation  within 
the  parenchyma  of  the  organ  of  masses  of  large  endothelial 
cells,  alveolarly  grouped,  and  surrounded  by  a  delicate  fibrous 
network.  The  cells,  which  are  loosely  arranged,,  vary  from  20 
to  40  /A  in  diameter,  contain  an  abundant  almost  homogeneous 
cytoplasm,  and  have  one  or  more  small  densely  basic  nuclei. 
Similar  groups  of  cells  are  found  in  the  liver,  the  bone-mar- 
row, and  the  lymphatic  glands.  The  exact  nature  of  this 
cellular  invasion  of  the  hematopoietic  organs  is  still  a  moot 
point  among  different  investig'ators,  but  the  general  trend  of 
opinion  fixes  their  origin  as  endothelial. 

The  clinical  diagnosis  of  splenic  anemia  is  based  upon  the 
leading  features  of  the  syndrome  such  as  the  idiopathic  spleno- 
megaly, a  hemorrhagic  tendency,  and  a  well-defined  anemia 
attended  by  disproportionate  hemoglobin  loss  and  by  distinct 
leucopenia  with  relative  lymphocytosis.  The  course  of  the 
disease,  furthermore,  is  unduly  prolonged,  and  the  subject 
shows  evidences  of  symptom-groups  variously  referable  to  the 
anemia  (asthma,  dyspnea,  vertigo,  cardiac  palpitation,  hemic 
murmurs,  edema)  ;  to  the  hemorrhagic  diathesis  (epistaxis, 
hematemesis,  hematuria,  petechia)  ;  and  to  the  splenic  tumor 
(pain,  distension,  ascites).  To  these  principal  findings  must 
be  added  the  absence  of  enlarged  superficial  lymphatic  glands, 
and,  in  the  Gaucher  type  of  the  disease,  the  presence  of  an 
appreciable  increase  in  the  size  of  the  liver. 

TREATMENT. 

One  of  the  first  essentials  of  treatment  is  provision  for  the 
patient  of  a  proper  hygienic  environment,  with  all  that  the 
term  implies  relating  to  fresh  air,  rest,  and  a  nutritious  pala- 
table dietary. 


50  DISEASES    OF    THE    BLOOD. 

The  knife  affords  the  only  radical  cure  for  splenic  anemia, 
and  it  is  an  acknowledged  fact  that  in  approximatel}-  70  per 
cent,  of  early  cases  splenectomy  are  followed  by  a  rapid  dis- 
appearance of  the  anemia  and  the  other  features  of  the  dis- 
ease and  finally  by  a  complete  and  permanent  cure.  Par- 
ticularly favorable  is  the  outlook  when  the  operative  proce- 
dure is  preceded  by  transfusion.-*^  and  in  cases  recognized  be- 
fore the  disease  has  worked  its  widespread  systemic  inroads. 
Unfavorable  in  prognosis  are  all  intense  grades  of  anemia,  ex- 
cessive enlargement  of  the  spleen  and  liver,  and  the  super- 
vention of  the  changes  incident  to  Banti's  disease.  W.  J. 
]Mayo^3  and  jMiller-*^  have  reviewed  the  surgical  treatment, 
and  the  reader  is  "referred  to  this  work  for  authoritative  data 
on  the  subject. 

The  .r-rays  also  have  been  used,  more  as  a  palliative  than 
as  a  curative  measure,  for  although  systematic  radiation,  such 
as  is  practised  in  leukemia,  tends  to  diminish  the  size  of  the 
spleen,  and  in  general  to  improve  the  other  symptoms,  this 
method  of  therapv  does  little  more,  and  in  no  sense  can  be 
considered  curative. 

The  foregoing  remarks  also  apply  to  the  use  of  iron, 
arsenic,  and  other  hematinics,  useful  as  adjuncts  to  splenec- 
tomy, but  never  an  adequate  substitute  for  this  operation. 

INFANTILE  SPLENIC  ANEMIA. 

This  obscure  type  of  infantile  anemia  is  a  doubtful  clinical 
entitv.  although,  for  convenience  sake,  it  is  permissible  to 
regard  it  as  a  form  of  primary  anemia  excited  by  some  un- 
known toxic  factor.  It  corresponds  to  von  Jaksch's  "Anemia 
infantum  pseudoleukaemica,"*-"^  and  the  "Anemia  splenica  in- 
fettiva  dei  bambini"  of  the  Italian  school. ^*5 

The  disease  in  question  is  limited  to  young  children,  occur- 
ing  especiallv  in  those  of  the  male  sex.  and  is  prone  to  affect 
the  twins  of  a  famih'  rather  than  several  of  the  other  children. 
The  chief  clinical  features  include  acute  secondary  anemia; 
high,  persistent  leucocytosis ;  and  enlargement  of  the  spleen, 
liver,  and  lymphatic  glands. 

With  tolerable  constancy,  prolonged  breast-feeding,  con- 
genital syphilis,  rachitis,  and  tuberculosis  have  a  more  or  less 


INFANTILE    SPLENIC   ANEMIA.  51 

significant  causal  role,  although  it  must  be  admitted  that  the 
exact  relation  of  the  foregoing  conditions  to  infantile  splenic 
anemia  is  conjectural. 

The  blood  changes  observed  most  commonly  relate  to  an 
unduly  low  hemoglobin  figure  with  a  less  striking  erythrocyte 
loss,  and  a  high  leucocyte  count  in- which  a  cellular  "hetero- 
morphism"  prevails — that  is,  the  excess  of  leucocytes  is 
largely  made  up  of  atypical  forms  transitional  between  the 
two  types  of  lymphocytes,  large  hyaline  cells  and  myelocytes, 
and  neutrophilic  and  eosinophilic  forms.  Large  numbers  of 
normoblasts  and  occasional  neutrophilic  myelocytes  also  are 
a  conspicuous  feature  of  the  blood  picture. 

TREATMENT. 

The  treatment  of  this  variety  of  splenic  anemia  is  essen- 
tially the  same  as  that  of  other  blood  deteriorations  of  simi- 
lar intensity  and  development,  but  aside  from  the  free  use  of 
appropriate  hematinics,  preventive  measures  against  various 
intercurrent  infections  are  urgently  demanded,  together  with 
the  care  of  the  potential  factor  of  the  disease,  be  it  lues, 
rachitis,  or  tuberculosis.  With  intelligent  management  this 
type  of  anemia  can  be  arrested  in  approximately  80  per  cent, 
of  cases,  according  to  data  given  by  Rotch.'*''' 

Iron  and  arsenic,  then,  are  the  directly  curative  drugs ;  and 
codliver  oil,  olive  oil,  mercurial  inunctions  and  the  rest  of  the 
antisyphilitic  regimen  constitute  the  equally  important  corre- 
lative measures  to  be  adopted. 

For  a  child  two  years  of  age  (and  splenic  anemia  rarely 
progresses  untreated  beyond  this  age-limit)  it  would  be  ap- 
propriate- to  give,  by  intramuscular  injection,  either  citrate  of 
iron  in  1-grain  (0.065  Gm.j  doses,  daily;  or  sodium  cacodylate 
in  the  same  amount,  on  alternate  days,  in  an  endeavor  thus 
permanently  to  increase  the  hemoglobin  and  erythrocyte 
values,  and  to  bring  about  a  subsidence  of  the  high  leucocyte 
counts. 

As  a  supplement  to  this  drug  therapy,  a  generous  diet, 
with  a  large  ration  of  fats,  red  meats,  milk,  and  carbohydrates 
is  indicated.     (See  Rickets.) 

The  surgical  treatment  of  infantile  splenic  anemia  deserves 
mention  as  a  possible  curative  measure,  although  in  no  sense 


52  DISEASES    OF    THE    BLOOD. 

does  it  play  the  part  that  one  credits  it  with  in  the  adult  form 
of  this  disease.  Giffin"^'^  has  studied  in  detail  the  results  of 
splenectomy,  both  in  the  adult  and  in  the  infantile  form,  and 
his  instructive  paper  should  be  consulted  by  those  interested 
in  this  method  of  treatment.  The  results  of  the  surgical  treat- 
ment of  the  infantile  form  are  in  no  wise  comparable  to  those 
afforded  by  the  simple  use  of  iron,  arsenic,  and  the  other 
means  of  blood  building  noted  in  a  foregoing  paragraph. 

PURPURA. 

The  term  purpura  relates  to  a  symptom,  and  in  no  sense 
refers  to  a  specific  disease.  The  many  attempts  made  in 
various  textbooks  to  describe  purpura  as  a  distinct  disease 
have  resulted  in  a  number  of  sub-divisions  and  headings  which 
it  is  not  necessary  to  consider  here  in  detail.  The  essential 
morbid  process  at  work  in  the  various  types  of  purpura  is  a 
spontaneous  hemorrhagic  extravasation  of  blood  into  the  skin, 
mucous  membranes,  and  viscera. 

Ordinarily  purpura  appears  as  purple  patches  upon  the 
dermal  and  mucosal  surfaces,  these  areas  of  discoloration  usu- 
ally being  discreet,  and  but  rarely  coalescent.  They  are  prone 
to  occur,  as  a  toxic  evidence,  in  many  septic  conditions,  and, 
indeed,  it  w^ould  seem  that  in  the  vast  majority  of  instances 
infection  and  sepsis  are  responsible  for  the  symptom.  While 
no  specific  micro-organism  is  associated  with  purpura,  the 
symptom  arises  not  infrequently  in  bacterial  infections  such 
as  cerebrospinal  ("spotted")  fever,  pyemia,  general  septicemia, 
and  pneumonia.  The  term  "cachectic  purpura,"  associated 
with  tuberculosis  and  Bright's  disease,  is  readily  seen  to  be 
of  an  infectious  origin ;  and  so  is  the  "neurotic  purpura"  inci- 
dent to  locomotor  ataxia,  although  here,  of  course,  the  Spiro- 
chcEta  pallidum  is  the  provocative  infection.  "Mechanical  pur- 
pura" occurring  in  the  venous  stasis  of  whooping-cough  is  now 
known  to  be  of  bacterial  origin.  Arthritic  purpura,  which  is 
the  "purpura  rheumatica"  of  past  medical  generations,  is  now 
believed  to  originate  from  septic  foci  somewhere  in  the 
economy. 

The  blood  picture  of  purpura  suggests  the  action  of  some 
specific  poison  to  the  blood  plaques,  with  a  coincident  hemo- 


PURPURA.  53 

lysis  affecting  the  number  and  vitality  of  the  erythrocytes. 
Thus,  in  a  well  defined  case,  the  plaques  are  unduly  scanty ; 
the  hemoglobin  percentage  ranges  from  20  to  70 ;  and  the 
erythrocytes  vary  in  number  from  1,000,000  to  3,500,000  per 
cubic  millimeter,  and  show  evidences  of  moderate  structural 
deterioration ;  the  leucocytes,  which  may  be  abnormally 
numerous,  are  not  constantly  altered.  Hematopexis  is,  as 
a  rule,  delayed,  especially  in  purpurics  with  striking  reduc- 
tion of  the  plaque  count,  although  this  change  is  not  constant. 
The  so-called  "bleeding-time"  of  the  blood  in  purpura 
invariably  is  greatly  prolonged.  This  is  estimated  by  timing 
the  persistence  of  oozing  from  a  needle  prick,  which  normally 
ceases  within  two  or  three  minutes,  while  in  a  purpuric 
it  may  last  for  as  many  hours.  (Hayem.'*^)  In  this  con- 
nection the  reader  should  consult  the  recent  experimental  work 
of  Lee  and  Robertson^o  on  the  subject  of  antiplaque  serum 
and  its  action  on  the  clotting  of  the  blood. 

Purpuric  spots  vary  in  size  and  in  color;  when  small  and 
pin-pointed  in  size  they  are  called  petechia:  ("flea-bite")  ; 
when  large,  reaching  the  size  of  perhaps  3  millimeters,  they 
are  termed  ecchymoses.  First  occurring  as  bright  red  spots, 
uneffaced  by  pressure,  they  gradually  become  darker,  and 
eventually  fade  to  brownish  stains. 

Purpura  Simplex.  This  condition  arises  during  the  course 
of  frank  infectious  processes :  pyemia,  septicemia,  and  malig- 
nant ■  endocarditis  produce  ecchymoses  that  may  be  very 
abundant.  Typhus  fever  is  characterized  by  a  purpuric  rash, 
and  the  acute  infectious  diseases  of  childhood,  such  as 
measles  and  scarlet  fever,  begin  with  purpuric  spots,  and  are 
differentiated  by  temperature  changes,  symptoms  of  consti- 
tutional infection,  and  the  subsequent  course  of  the  disease. 
S.  Weir  Mitchell  reported  purpuric  extravasations  following 
the  bite  of  snakes.  In  cancer,  in  Hodgkin's  disease,  in  scurvy, 
and  in  the  debility  of  old  age  purpuric  extravasations  are  fre- 
quently features  of  the  clinical  picture. 

The  petechial  rash  which  follows  the  administration  of 
certain  drugs  may  well  be  included  under  purpura  simplex. 
Copaiba,  quinin,  belladonna,  mercury,  ergot,  and  the  iodids 
produce  eruptions  which  may  be  so  classified.  It  is  interesting 
to  note  that  the  employes  of  rubber  factories  frequently  pre- 


54  DISEASES    OF    THE    BLOOD. 

sent  a  purpura  which  is  attributed  to  their  coming  in  contact 
with  benzol,  a  preparation  used  as  a  solvent  for  rubber. 

Purpura  Hemorrhagica.  This  condition  is  known  as  the 
morbus  maculosis  of  Werlhof.  It  is  seen  in  frail  young  girls. 
After  a  few  days  of  prodromal  languor  and  lassitude,  purpuric 
spots  make  their  appearance,  rapidly  increasing  in  number 
and  size.  This  eruption — and  indeed  the  same  may  be  said 
of  most  purpuric  extravasations — is  not  confined  to  the  sur- 
face of  the  skin  alone,  but  also  occurs  upon  the  mucous  sur- 
faces of  the  body ;  hemoptysis,  hematemesis,  and  bleeding 
from  the  bowel  {melcna)  may  thus  induce  a  serious  loss  of 
blood,  and  should  the  extravasation  take  place  within  the 
brain,  cerebral  symptoms  and  even  death  may  take  place. 

Henoch's  purpura  is  a  term  employed  to  describe  the 
severe  gastro-intestinal  symptoms,  pain,  vomiting,  and  diar- 
rhea, which  ensue  when  the  rash  invades  the  gastro-intestinal 
tract,  usually  in  children.  Purpura  peliosis  rheumatica  is  also 
known  as  Schonleins  disease.  This  condition,  which  frequently 
follows  exposure  to  cold  and  dampness,  is  characterized  by  the 
association  of  multiple  arthritis,  urticarial  wheals,  and  pur- 
puric extravasations.  The  kidneys  are  usually  implicated,  as 
first  evidenced  by  an  albuminous  urine  charged  with  tube  casts. 
The  majority  of  persons  so  affected  recover,  or  they  may  drag 
out  a  miserable  and  incapacitated  existence  for  a  prolonged 
period  and  finally  succumb. 

TREATMENT. 

The  treatment  of  purpura  is  a  treatment  of  the  underlying 
condition  or  disease,  of  which  the  purpura  is  but  a  symptom. 
Foci  of  infections  should  be  sought  for  and  properly  relieved. 
If  acute  articular  rheumatism  seems  to  be  the  underlying 
cause,  the  salicylates  are  indicated,  in  dosage  varying  from  5 
to  15  grains  (0.32  to  1  Gm.)  depending  upon  the  requirements 
of  a  given  case,  or  one  of  the  less  irritant  aspirins  may  be 
preferred — aspirin,  novaspirin,  or  diaspirin.  If  S3'philis  be  the 
provocative  infection,  iodids  and  salvarsan  should  be  ex- 
hibited ;  if  pyorrhea,  oral  sepsis,  or  dental  caries  be  at  fault, 
such  exciting  conditions  must  be  relieved.  A  properly  selected 
diet,  excluding  those  foods  which  would  g'ive  rise  to  gastro-in- 
testinal disturbances,  is  to  be  combined  with  fresh  air  and  a 


PURPURA.  55 

hygienic  manner  of  living'.  The  anemia  which  is  associated 
with  many  cases  of  purpura  indicates  the  use  of  iron,  prefer- 
ably in  the  form  of  Blaud's  pill.  Fowler's  solution  (Liquor 
potassii  arsenitis)  is  administered  in  gradually  ascending  doses 
of  1  drop  (0.06  mil)  a  day  until  the  physiologic  tolerance  of 
the  drug  is  reached,  the  dose  being  then  reduced  1  drop  (0.06 
mil)  a  day  until  it  reaches  the  initial  minimum  administration 
of  3  drops  (0.18  mil).     (See  Secondary  Anemia,  p.  4.) 

Inasmuch  as  purpura  is  often  associated  with  a  delay  in 
the  coagulability  of  the  blood,  calcium  lactate  may  be  ad- 
ministered in  5-grain  (0.3  Gm.)  doses  four  times  daily  for  a 
period  of  three  or  four  days.  Calcium  chlorid  in  the  same 
dose  is  also  used  in  the  slow  hematopexis  of  purpurics,  with 
the  understanding,  however,  that  both  the  chlorid  and  the 
lactate  of  calcium,  if  given  too  freely,  diminish  the  blood's 
clotting  power.  Serums  or  defibrinated  blood  may  be  em- 
ployed by  direct  infusion,  and  often  exhibit  a/  remarkably 
beneficial  effect  where  the  hemorrhages  are  of  considerable 
number. 

For  the  profuse  bleeding  incident  to  purpuric  conditions, 
injections  of  gelatin  have  an  essential  place  in  the  therapy, 
inasmuch  as  this  material  unquestionably  increases  the  blood 
coagulability.  Preferably  the  gelatin  is  used  in  a  solution  of 
7  grains  to  1^  ounces  (0.46  Gm.  to  45  mils)  of  sterile  water.  A 
single  injection  of  this  solution  may  be  sufficient  to  control 
the  hemorrhage ;  but  there  is  no  contraindication  to  its  repe- 
tition as  often  as  necessary.  Thus,  gelatin  is  useful  in  imme- 
diately controlling  a  hemorrhage,  while  the  drug  mentioned  in 
the  above  paragraph  is  more  useful  as  a  prophylactic  of  this 
accident. 

The  injection  of  human  whole  blood,  in  amounts  of  ap- 
proximately ^  fluidounce  (15  mils)  has  given  gratifying  re- 
sults in  many  instances.  Instead  of  human  blood,  horse  serum 
may  be  used  with  excellent  results,  especially  in  purpura 
hemorrhagica.  Schlenker^i  advises  the  injection  of  this 
agent  in  ten  consecutive  daily  doses  of  2^  fluidrams  (10  mils) 
each. 

In  those  cases  of  purpura  in  which  the  number  of  blood 
plaques  is  distinctly  subnormal,  this  deficiency  may  be  com- 
pensated promptly  by  the  use  of  one  of  the  newer  thrombo- 


,^6  DISEASES    OF    THE    BLOOD. 

plastic  agents,,  such  as,  for  example,  kephalin  or  coag-ulen. 
The  latter,  for  man}^  reasons,  is  preferable,  and  is  given,  either 
intravenously,  injecting  SjA  fluidrams  (20  mils)  of  a  5  per  cent, 
aqueous  solution ;  or  b}^  mouth,  giving  ever^^  fifteen  minutes 
1  tablespoonful  (15  mils)  of  a  solution  made  by  adding  75 
grains  (5  Gm,)  of  coagulen  to  2  ounces  (60  mils)  of  normal 
saline  solution. 

Emetin  hj^drochlorid,  in  y^-grain  (0.32  Gm.)  intramuscular 
injections,  is,  as  a  rule,  curative  in  the  average  example  of 
purpura,  but  its  use  must  be  persistent  to  obtain  this  effect, 
inasmuch  as  tlie  first  few  doses  but  aggravate  the  symptoms 
that  later  disappear  mider  the  drug's  prolonged  exhibition. 

On  the  basis  that  certain  examples  of  purpura  are  conse- 
quent to  disturbances  of  the  suprarenals  (loss  of  vasocon- 
strictor substance),  it  is  reasonable  to  prescribe  adrenalin  in 
such  instances.  This  animal  extract  usually  is  used  in  the 
form  of  adrenalin  chlorid  in  a  1 :  1000  aqueous  solution,  of 
which  5  to  30  minims  (0.30  to  1.9  mils)  are  given  by  mouth, 
or  by  hj^podermic  injection,  several  times  daily,  as  the  occa- 
sion demands.  Oil  of  turpentine  is  a  remedy  of  good  reputa- 
tion for  controlling  the  bleeding  of  apparently  idiopathic  t5"pes 
of  purpuric  extravasations,  being  given  in  10-  or  15-  grain 
(0.65  or  1  Gm.)  doses  three  or  four  times  a  da3^  It  is  un- 
necessary to  add  that  any  circumstances  or  any  drugs,  such 
as  exercise  or  cardiac  stimulants,  which  cause  an  increase  of 
arterial  pressure,  also  excite  an  increase  of  the  extravasations, 
and  therefore  are  to  be  avoided. 

HEMOPHILIA. 

Hemophilia  is  a  condition  restricted  to  the  male  sex, 
characterized  by  an  inherited  tendency  toward  inordinate 
spontaneous  and  traumatic  hemorrhages.  The  disorder  is 
attributable  to  a  congenital  deficiency  in  hematopexis,  and 
is  also  known  b}^  the  s^monymous  term,  "hemorrhagic  dia- 
thesis," which  seems  better  descriptive  of  the  condition  than 
is  the  Greek  work  "hemophilia."  meaning  "love  of  blood." 
Hemophilia  is  a  very  curious  and,  fortunatel}?^,  a  very  rare 
condition.  In  order  to  be  classified  as  a  "bleeder,"  it  is  quite 
necessarj^  that  one  should  have  exhibited  this  tendency  from 


HEMOPHILIA.  57 

infancy.  Injuries  of  a  remarkably  trivial  nature  may,  in  those 
of  the  hemorrhagic  diathesis,  induce  an  uncontrollable  loss  of 
blood,  which  in  certain  instances  may  prove  fatal.  A  slight 
blow  upon  the  nose,  not  of  sufficient  severity  to  induce  a 
simple  congestion  in  an  ordinary  individual,  may  cause  an 
alarming  hemorrhage  in  the  hemophiliac;  and  the  extraction 
of  a  tooth  is  capable  of  exciting  a  free  hemorrhage  whose  per- 
sistence and  extent  primarily  leads  to  the  discovery  of  the 
condition.  The  loss  of  blood,  however,  is  not  confined  to  sur- 
face injuries  alone,  but  may  follow  the  bruising  of  a  joint,  in 
which  event  bloody  extravasations  maj'-  produce  a  hemoar- 
thritis,  while  serous  hematomas  are  prone  to  form  subcu- 
taneoush'  and  in  the  muscle  sheaths.  To  these  tAvo  details 
of  the  clinical  picture  (arthritic  effusions  and  serous  hema- 
tomas) great  diagnostic  value  is  attached.  Inconsequential 
injuries  to  the  mucous  membranes  may  cause  intractable 
hemorrhage. 

The  physiologic  changes  which  would  cause  a  vessel  to 
continue  bleeding  after  the  formation  of  a  clot  are  not  as 
yet  understood;  it  has,  however,  been  determined  that  the 
coagulation  time  of  the  blood  is  much  delayed,  recent  investi- 
gations indicating  that  the  normal  coagulation  time  of  three 
minutes  is,  in  the  hemophiliac,  prolonged  to  as  much  as  40  or 
60  minutes. 

The  essential  factor  of  the  slow,  imperfect  clotting  of 
hemophilic  blood  is  still  a  disputed  point  among  phj^siologists. 
It  has  been  attributed  by  Howell, ^^  on  most  rational  grounds, 
to  a  reduction  of  the  blood's  prothrombin  content,  presumably 
consequent  to  some  functional  change  in  the  plaques,  from 
which  this  substance  is  derived.  The  recent  studies  of  Hur- 
witz  and  Lucas. -'3  who  found  great  fluctuations  in  the  pro- 
thrombin of  hemophilic  plasma,  attest  the  correctness  of 
Howell's  theor\%  in  contrast  to  the  older  premises  that  a  de- 
ficiencv  of  thrombokinase,  thrombozym,  and  calcium  was  the 
factor  of  the  imperfect  hematopexis. 

Much  has  been  written  concerning  the  advice  proper  for 
the  physician  to  give  to  those  who  exhibit  this  inherited  tend- 
ency to  bleed,  and  who  are  contemplating  matrimony.  Earlier 
thought  on  this  subject  has  indicated  that  the  male  of  a  fam- 
ily of  bleeders  who  is  himself  not  a  bleeder  may,  with  perfect 


58  DISEASES    OF    THE    BLOOD. 

safety,  marty  a  woman  who  is  not  a  bleeder;  on  the  other 
hand,  a  woman  who  comes  of  a  famih-  of  bleeders,  and  who  is 
not  herself  a  bleeder,  maj^  transmit  the  family  tendency  to 
her  offspring,  and  hence  it  has  not  been  considered  desirable 
that  she  should  marry.  It  is  not  germane  here  to  discuss  the 
moral  or  religious  privilege  of  the  physician  to  give  such 
purely  prophylactic  advice  on  affairs  that  so  intimately  con- 
cern the  happiness  of  his  patient,  even  though  such  advice 
might  be  heeded ;  but  it  is  permissible,  however,  to  draw^  atten- 
tion to  the  observations  of  Sir  Lovell  Gulland,  who  informs  us 
tliat  **some  famity  histories  have  recently  been  published  in 
which  the  females  and  not  the  males  have  been  affected ;  and 
in  some  of  these  the  transmission  has  been  made  through  the 
male  side  of  the  house ;  while  in  at  least  one  case  there  has 
been  a  reversal,  the  females  having  transmitted  it  in  earlier 
generations,  the  males  in  the  later." 

The  induction  of  hemorrhage  in  individuals  so  afflicted 
may  be^  as  already  noted,  due  to  slight  injuries,  or  even  ma}' 
arise  spontaneously.  In  the  latter  event,  a  sense  of  physical 
well-being  and  exhiliration  frequently  precedes  the  onset  of 
the  hemorrhage.  Upon  the  appearance  of  such  aura,  it  w^ould 
not  be  ill-advised  to  suggest  that  the  patient  take  a  laxative, 
and  that  he  restrain  himself  from  exercise  and  emotional  ex- 
citement, with  the  view  of  averting  a  loss  of  blood.  It  is  cus- 
tomary with  careful  surgeons  to  inquire  whether  or  not  this 
inherent  tendencj^  to  bleed  exists  in  prospective  operative 
cases;  and  it  would  seem  to  be  equally  advisable  for  the  den- 
tist to  make  similar  inquiries  preceding  the  extraction  of  the 
first  tooth. 

Certain  differences  between  hemophilia  and  purpura  must 
be  recalled,  in  order  to  differentiate  the  two  conditions  which, 
in  the  t^^pical  instance,  present  contrasting  points  of  discrimi- 
nation.^"* Hess's  studies  of  the  blood  in  these  hemorrhagic 
disorders  show  that  in  the  hemophiliac  subcutaneous  puncture 
of  the  skin  is  rarely  followed  by  an  area  of  hemorrhagic  ex- 
traA^asation,  while  in  purpura  a  consequence  of  this  sort  is 
virtually  constant.  In  hemophilia,  moreover,  the  application 
of  a  tourniquet  to  the  upper  arm  produces  no  objective  sign, 
but  in  purpura  this  procedure  causes  petechial  hemorrhages 
upon  the  forearm  below  the  point  of  constriction.     Finally,  in 


HEMOPHILl.\-  59 

hemophilia  great  delay  of  hematopexis  and  no  striking  diminu- 
tion of  the  plaque  count  are  the  rule,  in  contrast  to  the  slightly 
prolonged  coagulation  time  and  subnormal  number  of  blood 
plaques  in  purpura. 

TREATMENT. 

The  treatment  of  hemophilia  productive  of  the  most  bril- 
liant results  consists  of  the  use  of  the  various  blood  serums, 
of  which  normal  human  serum  is  by  far  the  safest  and  most 
satisfactory-,  chiefl}-  because  it  contains  no  foreign  protein,  and 
hence  the  risk  of  by-effects  need  not  be  apprehended.  The 
serum  of  the  horse  and  the  rabbit  also  are  employed,  but  with 
these  that  peculiar  reaction  known  as  "serum  sickness"  must 
be  reckoned  with ;  this  alarming  consequence  occasionally-  pro- 
vokes hyperpyrexia  and  an  urticarial  scarlatiniform  rash 
w-ith  numerous  systemic  disturbances,  occasionally  of  great 
intensity. 

The  serum  selected  is  most  satisfactorilv  administered  in- 
travenously, but  it  may  be  given  subcutaneously,  or  used  in 
the  form  of  a  compress  to  the  point  of  hemorrhage,  if  access- 
ible. Under  adequate  aseptic  precautions,  from  10  to  20  mils 
(254  to  5j2  io)  of  serum  are  given  intravenously  each  twent\-- 
four  hours  until  the  hemorrhage  is  under  control,  or  twice  this 
quantity-  if  the  subcutaneous  method  be  chosen.  In  favor  of 
the  intravenous  route  is  its  immediate  effectiveness  in  supplv- 
ing  normal  substances  essential  to  increase  a  deficient  blood 
coagulability-,  whereas  by  the  subcutaneous  technic  the  serum 
reaches  the  blood  stream  more  slowly,  and  doubtless  is  im- 
paired in  potency  by  the  action  of  the  tissues  from  which 
necessarily  it  must  be  absorbed. 

Horse-serum  may  be  administered  in  its  original  form,  or 
as  diphtheritic  antitoxin,  but  in  using  this  foreign  serum  one 
must  recall  the  possibilit\-  of  anaphylactic  reactions,  and  must 
rule  out  asthma,  hay-fever,  and  susceptibility  to  horse  emana- 
tions on  the  part  of  the  patient. 

In  case  the  transfusion  of  human  whole  blood  is  under- 
taken as  a  substitute  for  one  of  the  serums,  the  proper  pre- 
liminary^ agglutination  and  hemolysis  tests  should  be  made, 
and.  as  an  additional  safeguard,  a  Wassermann  test  of  the 
donor's  blood. 


60  DISEASES    OF    THE    BLOOD. 

Purely  on  empiric  grounds,  the  use  of  various  tissue 
extracts,  internally  and  locally,  sometimes  are  sufficient 
promptly  to  check  a  hemophilic  bleeding.  Of  these,  desiccated 
thyroid,  in  doses  of  from  2  to  4  grains  (0.13  to  0.26  Gm.), 
three  or  four  times  daily,  is  of  proved  utility,  not\vithstand- 
ing  the  fact  that  in  non-hemophilic  subjects  the  use  of  this 
substance  tends,  as  a  rule,  to  increase  the  tendenc}^  to  hemor- 
rhage. Among  the  other  animal  extracts  recommended  for 
hemostasis,  but  not  so  reliable  as  the  one  just  mentioned,  are 
tissue  extracts  of  the  liver,  pancreas,  spleen,  kidney,  and 
ovary.  Desiccated  suprarenal  gland,  OAving  to  the  potential 
vasoconstrictor  action  of  its  epineplirin  content,  has  been  used 
localty  to  control  hemorrhage,  but  not  with  great  success. 

The  various  preparations  of  calcium  have  a  distinct  place 
in  the  therapeusis  of  hemophilia,  and  for  a  long  period  have 
been  used  because  of  the  more  or  less  well  merited  properties 
of  this  substance  to  promote  clotting  of  blood  having  feeble 
power  of  hematopexis.  Calcium  lactate,  in  doses  of  5  grains 
(0.3  Gm.),  three  or  four  times  daily,  probabl}^  gives  better 
results,  and  is  less  disturbing  to  the  stomach  than  calcium 
chlorid,  in  similar  amounts ;  or  ordinary  lime-water,  adminis- 
tered in  tablespoonful  (15  mils)  doses  with  milk,  even,'  four 
to  six  hours,  ma}-  be  efficacious.  Inasmuch  as  an  excess  of 
calcium  salts  in  the  blood  tends  to  cause  a  delay  of  the 
coagulation  of  this  fluid,  caution  in  their  administration  is  to 
be  obser\-ed,  by  making  frequent  hematopexis  tests,  in  order 
thus  to  regulate  the  dosage  and  length  of  their  administration. 

The  attendant  anemia  is  to  be  investigated,  and,  if  well 
defined  or  progressive,  should  be  treated  on  general  principles 
— a  bountiful  dietan,',  with  a  generous  ration  of  milk,  fats,  and 
meats,  and  the  prescription  of  some  well  tolerated  and  active 
preparation  of  iron,  perhaps  supplemented  by  arsenic.  (See 
Secondan,-  Anemia,  p.  4.) 

In  order  to  control  the  disorder  b}-  altecting  the  underlying 
leucocyte  deficiency  and  the  defective  hematopexis,  the  ad- 
ministration of  nuclein  and  thymus  extract  has  been  sug- 
gested by  Sir  Almoth  Wright.-^^  who  holds  that  these  agencies 
in  combination  usually  are  sufficient  to  control  both  the  serous 
and  actual  hemorrhages  incident  to  this  condition. 

In  the  face  of  an  active  hemorrhage  and  the  failure  of  other 


ERYTHREMIA.  ,  61 

hemostatic  methods,  COo  has  been  administered  by  inhala- 
tion, on  the  ground  that  intravascular  coagulation  is  thereby 
accelerated.  Preferably  the  purified  carbonic  acid  gas,  con- 
tained in  steel  cylinders,  is  chosen,  but  in  an  emergency  it 
may  be  evolved  by  improvising  a  generator  made  of  a  large 
glass  bottle  with  two  openings,  the  lower  one  covered  with  a 
bit  of  gauze  or  muslin,  and  the  upper  provided  with  a  tight 
cork,  pierced  by  a  stout  glass  tube,  to  which  rubber  tubing  is 
fitted.  By  filling  such  a  home-made  apparatus  with  chalk,  and 
immersing  it  into  a  pan  of  vinegar,  CO2  is  rapidly  generated, 
and  may  be  fed  to  the  patient  by  means  of  the  tube. 

Should  an  operation  become  necessary  upon  a  hemophiliac 
the  coagulation  time  of  the  blood  may  be  increased  by  the 
preliminary  administration  of  chlorid  of  calcium  in  15-  to  30- 
grain  (1  to  2  Gm.)  doses  three  times  a  day,  supplemented  if 
needs  be  by  its  use  per  rectum. 

ERYTHREMIA. 

A  syndrome  distinguished  by  persistent  absolute  poly- 
cythemia, plethora,  cyanosis,  and  splenomegaly  was  first 
described  by  Vaquez,56  ^nd  subsequently  awarded  a  clinical 
status  by  Osler,^'''  by  whose  names  the  disorder  is  commonly 
referred  to  eponymically.  It  is  also  known  as  polycythemia, 
qualified  by  adjectives  such  as  true,  myelopathic,  cyanotic,  and 
splenomegalic. 

In  this  curious  disorder,  unlike  the  polycythemias  of 
physiologic  and  functional  types,  the  abnormally  high  ery- 
throcyte count  and  commensurate  hemoglobin  figure  are 
habitual  and  constant  features  of  the  clinical  picture,  which,  in 
addition,  is  distinguished  by  the  subject's  deep  cyanosis,  diffi- 
cult breathing,  enlarged  spleen,  tendency  to  spontaneous 
hemorrhages,  and  cerebral  symptoms,  such  as  headache,  ver- 
tigo, and,  rarely,  apoplectic  seizures. 

This  symptom-group,  due  to  excessive  erythroblastic  activ- 
ity of  the  bone-marrow,  arises  without  apparent  exciting 
cause,  and,  as  a  rule,  is  persistent  throughout  the  clinical 
course,  perhaps  marked  by  periods  of  transient  spontaneous 
remission.  Ordinarily  the  patient's  condition  remains  station- 
ary for  a  long  period,  while  others  succumb  to  cardiac  failure, 


62  DISEASES    OF   THE   BLOOD. 

or  die  with  signs  of  rapid  deepening  of  the  cyanosis,  or  of  a 
complication  set  up  by  intracerebral  hypertension. 

The  treatment  of  erythremia,  in  so  far  as  a  cure  of  the  dis- 
order is  concerned,  is  hopeless,  for  no  therapeutic  method  is 
available  for  the  control  of  the  essential  hemopoietic  hyper- 
activity. 

Venesection,  to  be  resorted  to  periodically,  is  a  means  of 
affording  temporary  relief  of  the  cyanotic  exacerbations,  and 
repeated  saline  purges  should  supplement  this  operation,  in 
■the  endeavor  thus  to  modify  the  subject's  excessive  cellular 
plethora.  Spontaneous  hemorrhage  is  sometimes  followed  by 
improvement,  for  obvious  reasons. 

Temporary  relief,  with  a  definite  diminution  in  the  size  of 
the  spleen  and  modification  of  the  hemoglobin  and  erythrocyte 
estimates,  has  been  reported  as  the  result  of  systematic  radia- 
tion with  the  A'-ray,  by  the  technic  used  in  the  treatment  of 
leukemia  {q.z'.). 

Of  the  numerous  drugs  recommended. for  the  relief  of  the 
symptom-complex,  the  iodids  (Hirschfeld^^),  and  quinin  and 
iodid  of  mercury  ointment  (Begg  and  Bullmore^^^  at  least 
merit  mention.  Oxygen  inhalations  have  been  attended  by 
equivocal  results,  and  the  same  is  true  of  arsenic,  sodium 
nitrate,  and  thyroid  substance,  all  of  which  have  been  used 
with  the  hope  of  a  cure.  Formerly  splenectomy  was  per- 
formed (Schneider^o,  Axel^i),  but  on  irrational  grounds,  for 
the  operation  has  invariably  proved  fatal,  and  is  no  longer 
advised. 

A  dry,  virtually  iron-free  diet,  with  no  alcohol,  and  a 
minimum  of  spices,  condiments,  tobacco,  tea,  and  cofTee  is 
helpful,  and  drugs  of  the  chalybeate,  coal-tar,  and  vasodilator 
groups  should  be  absolutely  proscribed. 

BIBLIOGRAPHY. 

1.  "Chlorosis,"  London,  1897. 

2.  Medizin.  Klinik.,  1915,  x,  80. 

3.  Brit.  Med.  Jour.,  1895,  i,  881 ;  ii,  1473. 

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6.  Berl.  klin.  Woch.,  1913,  C,  2409. 

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BIBLIOGRAPHY. 


63 


8.  Practitioner,  1888,  xci,  81 ;  Lancet,  1903,  i,  283,  et  sen.  ■  Brit    Med 
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19.  Russk.  Vrach.,  1914,  vi,  27. 

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26.  Berl.  klin.  Woch.,  1912,  Ixix,  1357. 

27.  Wien.  klin.  Woch.,  1912,  xxv,  1311. 

28.  Jour.  Amer.  Med.  Assn.,  1913,  Ivi,  1913. 

29.  Wien.  klin.  Woch.,  1914,  xxvii,  1141. 

30.  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  183. 

31.  St.  Louis  Med.  Rev.,  1909,  Iviii,  113. 

32.  Amer.  Jour.  Med.  Sc,  1904,  cxxvii,  563. 
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34.  Cited  hy  Graiwitz :    Verhandl.  d.  Berl.  Med.  Gesellsch.,  1909,  xxxix 
162.  '  ' 

35.  Lancet,  1906,  ii,  1654. 

36.  Cited  by  Grawitz :    Loc.  cit. 

Z7.  Modern  Clinical  Medicine,  N.  Y.,  1906,  368. 

38.  Texas  State  Jour.  Med.,  1916,  xi,  529. 

39.  Am.  Surg.  Jour.,  1916,  Ixiii,  35. 

40.  Ibid. 

41.  Amer.  Jour.  Med.  Sc,  1900,  cxix,  54;  Ibid.,  1902,  cxxiv  781 

42.  Ann.  Surg.,  1915,  xlviii,  315. 

43.  Ann.  Surg.,  1913,  Ixii,  158;  Ibid.,  1915,  cxiv,  172. 

44.  Jour.  Amer.  Med.  Assn.,  Ixvi,  716. 

45.  Wien.  klin.  Woch.,  1889,  ii,  435. 

46.  Arch.  Ital.  di  pediat.,  1890,  viii,  175. 

47.  "Pediatrics,"  Phila..,  1901,  Ed.  3  889 

48.  Ann.  Surg.,  1915,  xlviii,  679. 

49.  Compt.  rend.  Acad.  d.  sc,  1896,  cxxiii,  894. 

50.  Jour.  Med.  Research,  1916,  xxxiii,  323. 

51.  Jour.  Amer.  Med.  Assn.,  1916,  Ixvi,  20. 


64  DISEASES    OF    THE    BLOOD. 

52.  Arch.  Int.  Med.,  1914.  xiii,  l(i. 

53.  Ihid.,  1916,  xvii,  582. 

54.  Arch.  Int.  Med.,  1916,  xvii,  203. 

55.  Allbutt's  "System  of  Medicine,"  X.  Y.,  1909,  v,  937. 

56.  Bull.  Soc.  Med.  des  Hop.,  Paris,  1899,  xvi,  579. 

57.  Amer.  Jour.  Med.  Sc,  1903,  cxxiv,  187. 

58.  Berl.  klin.  Woch.,  1907,  xliv,  1302. 

59.  Edinburgh  Med.  Jour.,  1905,  xvii,  481. 

60.  A\'ien.  klin.  Woch.,  1907,  xx,  413,  et  seq. 

61.  Folia  Hematolog.,  1905,  ii,  685. 

62.  Jour.  Lab.  and  Clin.  Med.,  1917,  ii,  552. 

63.  Journal  of  the  American  Medical  Association,  1917,  Ixix,  1919. 

64.  St.  Paul  Med.  Jour.,  1917,  xix,  43. 

65.  Von  Noorden :    Merck's  Reports,  1917,  xxviii,  422. 

66.  Journ.  Amer.  Med.  Assoc,  1917,  Ixviii,  747. 


Diseases  of  the  Ductless  Glands 


BY 

CHARLES  E.  de  M.  SAJOUS,  M.D,  LL.D.,  Sc.D., 

Fellow  of  the  College  of  Physicians  ajid  of  th^  American  Philosophical 
Society;  Professor  of  Therapeutics,  Temple  University  of  Philadel- 
phia,  Department  of  Medicine,   etc. ; 

AND 

LOUIS  T.  DE  M.  SAJOUS,  B.S.,  M.D., 

Associate  Professor  of  Experimental  Therapeutics,  Temple  University 
of  Philadelphia,  Department  of  Medicine;  Instructor  in  Laryn- 
gology, Graduate  Medical  School  of  the  University  of  Pennsyl- 
vania. 


(65) 


Diseases  of  the  Ductless  Glands. 


FOREWORD. 

To  treat  intelligently  any  of  the  diseases  of  this  class,  it  is 
necessary  to  understand  with  some  degree  of  accuracy  the 
functions  of  the  organs  affected.  The  authors  deemed  it  ad- 
visable, therefore,  to  precede  the  disorders  of  each  organ  with 
a  summary  of  its  physiology.  Inasmuch,  however,  as  this 
phase  of  our  knowledge  is  still  shrouded  in  considerable  ob- 
scurity, the  more  salient  conceptions  are  alone  presented, 
selecting  those  which  seemed  most  clearly  to  explain  the  clin- 
ical phenomena  observed.  The  views  of  the  senior  author  are 
introduced  without  special  emphasis  among  the  many  sub- 
mitted, the  purpose  being  to  afford  the  reader  a  general  review 
of  the  subject  in  its  bearing  upon  the  diseases  to  which  the 
ductless  glands  are  liable.  Special  stress  has  been  laid,  how- 
ever, upon  the  treatment  of  these  diseases. 

DISEASES  OF  THE  ADRENAL  GLANDS. 

General  Considerations.  Each  adrenal  is  constituted  of 
two  portions — the  external  or  cortex,  and  the  internal  or 
medulla.  The  former,  the  cells  of  which  contain  lipoid  or  fat- 
like substances,  is  derived  from  the  same  mesoblastic  tissues 
as  the  primitive  kidney,  while  the  medulla  yields  the  "chro- 
maffin reaction,"  and  is  derived  from  the  sympathetic  system. 

The  cells  of  the  medulla,  disposed,  in  man,  in  columnar 
masses,  are  generally  separated  from  the  lumina  of  capillaries 
or  small  veins  only  by  an  endothelial  membrane  and  contain 
granules  soluble  in  water  and  in  alcohol,  but  insoluble  in  ether 
or  xylol,  which  embody  the  characteristic  property  of  chromaf- 
finity  and  impart  a  brown  coloration  to  the  cut  surface  as  a 
whole  when  fixed  in  formalin  containing  a  salt  of  chromic  acid. 
According  to  Stoerk  and  von  Haberer,i  the  chromaffin  sub- 
stance develops  in  the  form  of  intracellular  granules,  which, 

(67) 


68  DISEASES   OF   THE   DUCTLESS   GLANDS. 

when  sufficiently  dense,  diffuse  out  of  the  cells  into  the  ad- 
joining small  vessels,  and  appear  in  the  adrenal  venules  as  a 
yellowish  brown,  refractile,  mucoid  material.  This  material, 
held  to  constitute  the  adrenal  secretion,  passes  into  the  vena 
cava,  and  thence  into  the  general  circulation. 

The  adrenal  cortex  consists  essentially  of  columnar  epi- 
thelial cells  disposed  variously  in  spherical  or  oval  groups, 
parallel  columns,  or  thin,  anastomosing  cords  and  separated  by 
thin  partitions  of  connective  tissue.  As  in  the  medulla,  the 
parenchymal  cells  are  disposed  in  close  apposition  to  blood- 
vessels. A  special  characteristic  is  their  wealth  in  lipoid  gran- 
ules, believed  chiefly  to  be  made  up  of  cholesterin  esters.  As 
in  the  cells  of  the  medulla,  there  are  also  contained  in 
the  cortical  cells,  less  abundantly  than  the  main  product, 
other  granulations — some  pigment  granules — of  unknown 
significance. 

Both  portions  of  the  adrenals  receive  an  abundant  blood- 
suppl}'-,  brought  to  them  through  three  sets  of  arteries.  The 
medulla  receives  not  only  blood  which  has  circulated  through 
the  cortex  from  the  capsule  of  the  organ,  but  also  blood  reach- 
ing it  through  the  perforating  arteries  of  Srdinko,^  which 
travel  to  the  medulla  from  the  capsule  without  dividing.  Like- 
wise abundant  is  the  ner^^e  supply  of  the  adrenals,  especially 
in  their  medullary  portions.  Many  nerve-bundles,  which  pass 
through  the  capsule  and  cortex,  reach  the  chromaffin  tissues, 
around  the  cells  of  which  they  form  actual  arborizations. 
Plexuses  of  non-medullated  and  some  medullated  fibers,  con- 
nected with  sympathetic  ganglion  cells,  occur  in  the  capsule 
of  the  gland,  while  in  the  medullar)^  and  even  the  cortical  tis- 
sues themselves  are  also  to  be  found  interconnected  groups  of 
sympathetic  ganglion  cells. 

The  adrenal  medullse  embody  the  greater  part  of  the  chro- 
maffin tissue  existing  in  the  organs,  but  there  are  also  sub- 
sidian,-  chromaffin  structures,  viz.,  the  carotid  glands,  the  tym- 
panic glands,  the  parasympathetic  organ  of  Zuckerkandl — the 
latter  located  anteriorly  to  the  bifurcation  of  the  abdominal 
aorta — and  the  chromaffin  inclusions  in  the  sympathetic  gan- 
glia. .Subsidiary  interrenal  tissues,  or  "adrenal  rests,"  cor- 
responding in  cellular  structure  to  the  adrenal  cortex,  and  pos- 
sessing no  chromaffin   property,   likewise   exist  in   nearly   all 


DISEASES    OF    THE    ADRENALS.  69 

instances ;  they  occur  either  in  or  around  the  adrenals  them- 
selves or  the  kidneys,  in  the  vicinity  of  sympathetic  nerve 
plexuses,  in  or  near  the  liver  or  pancreas,  at  various  points  in 
the  retroperitoneal  space,  and  in  relation  to  the  reproductive 
organs,  e.g.,  along  the  spermatic  cord,  between  the  testicles 
and  epididymes,  in  the  testicles,  or  in  the  ovaries  or  broad  liga- 
ment. These  subsidiary  adrenal  tissues  are  capable  of  under- 
g'oing  a  considerable  degree  of  compensatory  hypertrophy 
where  the  main  repository  of  adrenal  tissues — the  adrenals 
themselves — has  been  gradually  destroyed  or  removed. 

Functionally,  the  two  portions  of  the  adrenals  appear  to 
play  different  roles.  Our  information  as  to  their  physiological 
activities  is  based  chiefly  upon  extirpation  experiments,  and 
upon  studies  of  the  effects  of  adrenal  extracts  or  principles. 
Whereas,  upon  removal  of  a  single  adrenal  little  inconvenience, 
as  a  rule,  results,  excision  of  both  adrenals  in  animals  regularly 
causes  death  within  thirty-six  hours.  Rapidly  developing  dis- 
ease of  both  adrenals  in  man  likewise  causes  early  death,  and 
sudden  destruction  of  a  single  adrenal,  as  by  hemorrhage,  may 
cause  death  where  the  opposite  organ  is  already  deeply  im- 
paired through  disease  of  its  vascular  or  nervous  supply. 

The  nature  of  the  (eventually  fatal)  efifects  of  adrenal 
destruction  upon  the  system  as  a  whole  is  suggested  by  vari- 
ous facts.  Bilateral  adrenalectomy  is  followed,  in  the  first 
place,  by  a  marked  fall  of  blood-pressure,  and  a  feeble,  frequent 
heart  action.  Injections  of  the  adrenal  principle,  adrenalin  or 
epinephrin,  on  the  other  hand,  induce  a  characteristic  rise  of 
the  blood-pressure  and  strengthening  of  the  heart  beat,  due  to 
direct  and  powerful  excitation  of  the  contractile  vessel  walls 
and  of  the  cardiac  muscle.  These  observations  suggest  that 
the  morbid  phenomena  attending  adrenalectomy  may  be  due, 
at  least  in  part,  to  removal  of  a  normal  supporting  influence 
exerted  upon  the  motor  functions  of  the  circulatory  tract,  pre- 
sumably by  the  adrenal  secretion  poured  into  the  blood-stream. 
The  marked  similarity  of  the  efifects  of  adrenalin  on  various 
structures  of  the  body  to  those  of  stimulation  of  the  sympa- 
thetic nervous  system,  whether  electrically  or  by  some  other 
means,  has  also  led  to  the  view  that  the  essential  role  of  the 
adrenals  is  to  afford  a  supporting  or  tonifying  influence  to  the 
entire  group  of  functions  under  control  of  this  system. 


70  DISEASES    OF    THE    DUCTLESS    GLANDS. 

According  to  Sajous,  Sr.,^  the  adrenal  secretion  influences 
respiration  and  general  metabolism.  After  passing  into  the 
blood,  it  normally  becomes  an  essential  constituent  of  the 
hemoglobin,  absorbs  oxygen  from  the  air  in  the  lungs,  and  sub- 
sequently, by  yielding  it  to  the  peripheral  cellular  structures, 
sustains  general  tissue  respiration.  Bernstein  and  Falta,^  in- 
deed, have  in  fact  noticed  that  injections  of  adrenalin  caused 
an  increased  consumption  of  oxygen  as  well  as  an  increased 
carbon  dioxide  excretion.  That  an  excess  of  adrenal  secretion, 
brought  about  by  the  injection  of  adrenalin,  tends  to  induce 
a  rise  in  the  body  temperature  is,  moreover,  a  well-known  fact ; 
conversely,  adrenal  insufficiency  leads  to  hypothermia. 

An  antitoxic  function  on  the  part  of  the  adrenals  has  been 
suspected  by  Abelous  and  Langlois,^  the  glands  being  pre- 
sumed normally  to  destroy  poisonous  products  of  muscular 
activity  as  well  as  toxic  materials  of  bacterial  origin.  Sajous, 
Sr.,  however,  holds  that  the  adrenal  secretion  carries  on  this 
antitoxic  function  only  in  conjunction  with  the  products  of 
other  ductless  .glands,  the  pancreas  and  thyroparathyroid  ap- 
paratus in  particular.  According  to  D.  E.  Jackson,^  one  of 
the  functions  of  the  adrenals  is  to  assist,  by  means  of  their 
internal  secretion,  in  counteracting  pathological  processes  or 
products  which  tend  to  cause  abnormal  constriction  of  the 
bronchioles — a  view  which  coincides  with  those  of  the  writers 
previously  mentioned. 

As  regards  the  influence  of  the  adrenal  secretion  on  the 
blood-pressure,  Stewart  and  Rogoff'  have  ascertained  that 
there  occurs  a  definite  rate  of  spontaneous  liberation  of  ad- 
renin  (epinephrin)  in  cats,  viz.,  0.0003  milligram  to  0.001  milli- 
gram a  minute  for  each  kilogram  of  animal;  yet  the  general 
trend  of  recent  experimental  work  has  been  against  the  con- 
clusion that,  physiologically,  epinephrin  acts  constantly  as  an 
augmentor  of  blood-pressure.  Hoskins  and  McPeek^  observed 
upon  practising  various  degrees  of  massage  over  the  adrenals, 
thus  liberating  varying  doses  of  adrenin  in  the  circulation,  a 
distinct  depression  from  small  discharges,  but  a  considerable 
rise  of  pressure  when  the  glands  were  vigorously  manipulated. 
The  same  experimenters  found,  however,  that  where  the 
initial  blood-pressure  was  very  low — 40  millimeters  Hg. — only 
purely  pressor  effects  could  be  obtained.    This  would  indicate 


DISEASES    OI'"    THE    ADREXALS.  71 

that  the  excretion  of  adrenin  is  in  at  least  one  sense  a  sustain- 
ing influence  on  vascular  tension,  serving-  to  increase  the  lat- 
ter when  it  tends  to  descend  below  normal.  This  view  of  the 
adrenals  as  an  emergency  organ  corresponds  with  the  well- 
known  findings  of  W.  B.  Cannon  in  cats,  that  under  the  in- 
fluence of  emotions  such  as  rage  or  fear,  or  of  great  excitement, 
an  excess  of  adrenin  is  automatically  discharged  into  the  blood- 
stream, the  results  being  an  increased  liberation  of  sugar  from 
the  liver,  a  prompt  abolition  of  fatigue,  increased  coagulating 
power  of  the  blood,  and  an  improved  flow  of  blood  to  the  heart, 
lungs,  central  nervous  system,  and  skeletal  muscles,  the  diges- 
tive processes  being  meanwhile  temporarily  inhibited.  That 
the  increased  adrenal  function  is  evoked  through  nervous 
action  is  indicated  by  the  experimental  observation  of  Macken- 
zie^  that  nervous  stimuli,  especially  of  the  sympathetic — 
piqure  or  splanchnic  excitation — cause  an  increased  secretion 
of  adrenin.  According  to  Sajous,  Sr.,io  the  pituitary  body  is 
directly  connected  with  the  adrenals  by  nerve-paths,  and  may 
thus  itself  influence  the  activity  of  these  organs.  J.  F.  Gas- 
kell,^i  noting  the  common  embryologic  origin  of  the  sympa- 
thetic nervous  system  and  the  chromaffin  cells,  expresses  the 
view  that  regulation  of  the  vascular  tree  in  general  is  effected 
in  a  twofold  manner,  viz.,  both  by  the  sympathetic  nerves 
(vasoconstrictor  fibers)  and  by  the  secretion  of  adrenin. 

Confirming  the  assertion  of  Sajous,  Sr.,  many  years  ago,i- 
that  certain  drugs  produce  tonic  effects  on  the  heart  through 
the  adrenals  rather  than  by  direct  stimulation  of  the  heart 
muscle,  Gleyi^  has  recently  reported  efifects  from  such  violent 
cardiac  poisons  as  anagyrin  and  nicotin  which  he  could  as- 
cribe only  to  the  adrenals,  and  has  been  led  to  recognize  the 
existence  of  a  class  of  heart  stimulants  which  act  through  these 
organs.  Finally,  Cannon  and  Cattelli^  have  observed  that 
adrenalin  in  a  small  dose  is  capable  of  markedly  increasing 
the  activity  of  the  thyroid  gland ;  the  same  result  was  ob- 
served when  the  splanchnic  nerves  to  the  adrenals  were  stimu- 
lated. A  strong  probability  is  thus  suggested  that,  besides 
directly  favoring  oxidation  through  secretion  of  epinephrin — 
the  previously  mentioned  conclusion  of  Sajous,  Sr. — the  ad- 
renals, when  stimulated,  increase  general  metabolism  through 
excitation  of  the  thyroid. 


72  DISEASES    OF    THE    DUCTLESS    GLANDS. 

In  conclusion,  it  should  be  mentioned  that,  according  to 
some,  the  removal  of  the  adrenal  cortices  in  bilateral  adrenalec- 
tomy plays  a  much  more  important  part  in  the  succeeding 
fatal  termination  than  has  hitherto  been  believed.  Voegtlin 
and  Macht^^  detected  in  the  adrenal  cortex  a  body  having  a 
digitalis-like  action,  and  Iscovesco^^  found  in  it  a  cardiotonic 
lipoid.  That  the  adrenal  cortex  is  capable  of  exerting  a  marked 
stimulating  influence  on  the  essential  organs  of  reproduction 
has  long  been  recognized. 

A  probable  influence  of  the  adrenals  upon  growth  in  gen- 
eral has  been  experimentally  noticed  by  F.  de  Mira,!'''  who, 
upon  removal  of  the  left  adrenal  in  the  young  cat  and  dog, 
found  the  growing  animals  smaller  and  thinner  than  controls 
from  the  same  litters ;  the  bones  in  particular  were  notably 
lighter  in  the  operated  animals. 

ADRENAL  INSUFFICIENCY  (HYPOADRENIA). 

Cases  of  insufficiency  of  the  adrenal  functions  (hypoad- 
renia;  hypoadrenalism)  may  conveniently  be  classified  into 
three  forms:  (1)  Functional  hypoadrenia,  in  which  the  ad- 
renals, while  not  organically  diseased,  are  functionally  im- 
paired through  hypoplasia,  or  because  of  debilitating  influ- 
ences, such  as  fatigue,  stan^ation,  etc.,  or  old  age.  (2)  Pro- 
gressive liA^poadrenia,  or  Addison's  disease,  in  which  the  func- 
tions of  the  adrenals,  either  directly  or  through  their  secretory 
nerves,  become  progressively  reduced  through  organic  lesions, 
such  as  tuberculosis,  cancer,  fibrosis,  etc.  (3)  Terminal  hypo- 
adrenia, a  more  or  less  tardy  complication  of  infectious  dis- 
eases and  toxemias,  due  to  exhaustion  of  the  secretory  power 
of  the  adrenals  from  previous  hyperactivity. 

Functional  Hypoadrenia.  The  symptoms  of  this  condition 
are  such  as  would  be  expected,  in  view  of  the  physiolog'ical 
properties  of  the  adrenals  already  mentioned,  to  result  from 
interference  with  the  activity  of  these  organs.  They  consist 
chiefly  of  general  motor  asthenia,  a  tendency  to  hypothermia, 
with  sensitiveness  to  cold  and  actual  coldness  of  the  extremi- 
ties, low  blood-pressure,  weak  heart-action  and  pulse, 
anorexia,  psychasthenia,  anemia,  and  slow  metabolism. 


DISEASES    OF   THE    ADRENALS.  73 

In  infancy  and  childhood  the  effects  of  hypoadrenia  due  to 
tardy  development  of  the  adrenals  become  manifest  particu- 
larly after  the  period  of  transference  of  immunizing  substances 
from  mother  to  offspring"  with  the  maternal  milk  has  termi- 
nated through  weaning.  A  persisting  hypoplasia  of  the  in- 
fantile adrenals,  thus  rendered  unable  properly  to  assume  the 
burden  of  adequate  tissue  oxidation  and  defence  against  in- 
fection, is  apt  to  result  in  pallor,  a  pasty  appearance,  or 
emaciation,  cold  hands  and  feet,  flabbiness  of  the  muscles,  a 
deficient  or  capricious  appetite,  and  an  unusual  susceptibility 
to  infections  of  all  types. 

In  the  adult,  inherently  weak  adrenals  lead  similarly  to  a 
feeble  circulation,  to  a  tendency  to  adiposis,  and  probably  to 
the  appearance  of  bronze  spots.  More  frequently,  however, 
the  condition  is  an  acquired  adrenal  weakness  due  to  exhaus- 
tion of  these  organs  through  excessive  secretory  activity.  A 
frequent  cause  of  temporary  adrenal  insufficiency  is  physical 
fatigue.  In  the  war  in  Europe,  many  instances  of  otherwise 
unaccountable  physical  depression,  with  a  tendency  to  hypo- 
thermia, following  repeated  arduous  military  tasks,  have  been 
definitely  ascribed  to  adrenal  exhaustion,  the  demands  upon 
these  organs  as  regards  general  oxidation  and  (according  to  the 
view  of  Abelous  and  Langlois,!^  in  overcoming  the  unusually 
abundant  toxic  products  of  muscular  activity),  having  tempor- 
arily overwhelmed  their  functionating  power.  In  a  number  of 
instances  Sergent's  white  line  phenomenon — generally  con- 
sidered indicative  of  adrenalin  deficiency — was  noted  by  Merk- 
len^^  in  the  presence  of  hypothermia  and  general  physical 
misery  in  soldiers.  Carl-^  observed  absence  of  the  chromaffin 
reaction  in  the  adrenals  of  a  bicyclist  who  had  succumbed  from 
extreme  exertion,  as  well  as  in  those  of  frogs  after  strychnin 
convulsions.  Other  possible  causes  of  temporary  adrenal  in- 
sufficiency are  deficient  food,  and  excessive  venery  and  mas- 
turbation. Sezary2t  recognizes,  applying  to  it  the  term  "hypo- 
epinephry,"  a  permanent  incapacit}^  of  the  adrenals  to  protect 
the  body  against  infection.  Experimental  work  by  F.  C. 
Mann-2  has  tended  to  indicate  that  adrenal  insufficiency  may 
contribute  or  lead  to  the  production  of  peptic  ulcers,  a  large 
percentage  of  dogs  and  cats  dying  after  adrenalectomy  show- 
ing such  ulcers  at  points  of  hemorrhage  in  the  gastric  mucosa. 


74  DISEASES   OF   THE   DUCTLESS   GLANDS, 

In  old  age  impairment  of  the  adrenal  functions  is  a  result 
of  the  retrogressive  changes  frequently  taking  place  in  these 
glands  in  later  adult  life.  Landau^^  found  the  adrenals  mark- 
edly shrunken  and  hypovascular  in  aged  subjects,  while  others 
have  found  distinct  fibrosis,  especially  in  the  medullary  por- 
tion, in  old  experimental  animals.  The  asthenia  of  old  age 
thus  finds  a  normal  explanation  in  the  attendant  defective 
supph'  of  adrenal  secretion,  and  the  possibility  is  even  to  be 
thought  of  that  integrity  of  the  adrenals  pla^'-s  an  important 
part  in  the  promotion  of  longevity. 

Prophylaxis  and  Treatment.  Much  is  possible  in  the  w^ay  of 
remedial  correction  in  each  of  the  three  types  of  functional 
hypoadrenia  mentioned.  In  the  infantile  cases,  distinct  pro- 
phylactic possibilities  are  presented,  the  aim  being  by  all 
means  to  obviate  such  early  injury  to  the  adrenals  and  other 
protective  organs  by  infection  or  intoxication  as  would  leave 
them  in  a  permanent  state  of  functional  impairment.  Espe- 
cially to  be  emphasized  in  this  connection  is  the  immunizing 
value  of  maternal  milk,  the  lack  of  which,  so  frequent  under 
prevailing  conditions  of  rather  indiscriminate  substitutional 
feeding-,  places  an  unnatural  strain  upon  the  autoprotective 
functions  for  which  they  are  at  the  time  practically  unpre- 
pared. 

Idiopathic  hypoplasia  of  the  adrenal  glands  is  doubtless  to 
be  guarded  against  largely  in  the  same  manner,  all  measures 
being  taken  to  secure  as  perfect  a  nutritive  condition  of  the 
infant  as  possible.  Of  these  measures,  proper  assimilation  of 
good  maternal  milk  is  obviously  the  most  essential,  and  where 
the  milk  of  the  child's  own  mother  is  at  fault,  that  of  a  healthy 
wet-nurse  is  to  be  sought  in  preference  to  any  other  form  of 
substitution. 

In  children  past  the  period  of  nursing,  the  prophylaxis  of 
hypoadrenia  consists  again  in  avoiding  excessive  strain  on 
the  adrenals  through  infection  and  intoxication.  The  use  of 
milk  free  from  dangerous  bacterial  contamination  continues, 
for  a  time,  to  be  one  of  the  essential  measures.  Proper  h3^giene 
in  the  school,  as  well  as  at  home,  are  also  necessar}^  features, 
and  the  advisability  of  preventing  at  any  time  a  severe  and 
continuous  absorptive  infection,  as  from  the  mouth  or  pharynx, 
is  likewise  to  be  borne  in  mind. 


DISEASES   01-    THE   ADRENALS.  75 

In  the  actual  presence  of  functional  hypoadrenia,  various 
remedies,  other  than  adrenal  gland  itself,  are  available.  In 
feeble  children  ten  or  twelve  years  of  age,  a  capsule  containing 
1  grain  (0.06  Gm.)  each  of  dried  thyroid  and  Blaud's  mass, 
with  2  grains  (0.12  Gm.)  of  dried  suprarenal,  given  three  times 
daily,  will  often  prove  very  beneficial,  especially  if  properly 
supported  by  hygienic  measures.  D'Qilsnitz^^  has  confirmed 
the  utility  of  dried  adrenal  gland  in  the  presence  of  moderate 
hypoadrenia  in  childhood,  manifested  in  retardation  of  growth 
and  of  walking,  emaciation,  flabbiness  of  the  muscles,  fatigue, 
physical  and  mental  indolence,  and  low  blood-pressure.  The 
frequent  efBcacy  of  small  doses  of  mercury,  in  the  form  of  the 
biniodide,  or  of  calomel,  as  a  stimulant  to  the  functions  pro- 
tecting the  system  against  infection,  including  that  of  the 
adrenals,  is  also  worth  remembering.  Meats,  and  especially 
milk,  are  of  marked  value  in  the  diet  in  these  cases,  and  where 
the  circulation  is  weak,  or  the  nervous  reflex  functions  as  a 
whole  apparently  inactive,  small  doses  of  digitalis  or  of  strych- 
nin are  likely  to  prove  of  service. 

The  functional  hypoadrenia  of  adults  is  frequently  suscept- 
ible of  improvement  or  correction  through  the  removal  of  in- 
fluences placing  an  undue  functional  burden  on  the  adrenals. 
In  the  temporary  adrenal  exhaustion  of  soldiers,  complete 
physical  rest  for  as  long  a  period  as  is  necessary  to  permit  the 
organs  to  recuperate  is  obviously  paramount.  The  strain  on 
the  adrenals  having  often  been  relatively  brief,  no  obstacle  may 
exist  to  an  eventual  complete  recovery  of  functional  power.  A 
significant  fact  in  these  cases,  however,  is  the  probable  harm- 
ful efifect  of  repeated  fatigue  in  the  presence  of  already  over- 
burdened adrenals.  Thus,  Morat  and  Doyon-^  refer  to  the 
aggravating  influence,  at  times  even  resulting  in  sudden  death, 
observed  upon  instituting  experimental  fatigue  in  animals  de- 
prived of  their  adrenals.  Furthermore,  not  only  is  the  physical 
incapacity  of  soldiers  with  exhausted  adrenals  a  feature  re- 
quiring attention,  but  their  powers  of  resisting  infection  are 
also  to  be  remembered  as  being  unfavorably  influenced  by  the 
adrenal  impairment.  To  stimulate  actively  the  functions  of 
fatigued  adrenals  by  drugs  would  obviously  tend  to  ulti- 
mately aggravate  the  hypoadrenia,  possibly  after  a  brief  period 
of  improvement.    The  use  of  dried  suprarenal  or  of  adrenalin, 


76  DISEASES    OF    THE    DUCTLESS    GLANDS. 

however,  to  make  good  temporarily  the  lack  of  adrenal  pro- 
duct or  products  in  the  system  is  not  open  to  this  objecion, 
and  has  actually  proven  of  considerable  remedial  value,  both  in 
accelerating'  recovery  from  the  hypoadrenic  depression  and  in 
protecting  the  individual  from  complicating  disorders  such  as 
infection.  Josue^^  notes  that,  to  obtain  the  best  results,  gener- 
ous dosage  of  either  the  pure  principle  or  the  dried  gland  is  re- 
quired. He  has  found  adrenalin  by  the  mouth  efficient  if  used 
to  the  amount  of  1  to  4  or  even  5  mils  (15  to  80  m.)  of  the 
1 :  1000  solution  in  a  day,  in  divided  doses.  Three  mils  could 
thus  be  given  daily  for  a  month  or  more  without  harm.  In  the 
hypodermic  use  of  the  drug  he  recommends  a  "slow  absorp- 
tion" method,  carried  out  by  injecting  under  the  skin  250  to 
500  mils  (3^  to  1  pint)  of  normal  saline  solution  to  which  1 
mil  (15  m.)  of  adrenalin  solution  and  0.01  gram  (%  gr.)  of 
novocain  have  just  been  added.  The  dosage  is  0.5  to  2  mils 
(8  to  30  m.)  a  day,  0.5  mil  (^8  in.)  being  preferably  not  exceeded 
as  the  single  dose.  Extracts  of  the  whole  adrenal,  given  by 
mouth  in  daily  amounts  of  0.2  to  0.4  gram  (3  to  6  gr.),  in  two 
doses,  or  hypodermically  in  a  dail}^  amount  of  0.1  gram  (1^ 
gr.),  in  some  cases  even  proved  distinctly  superior  to  ad- 
renalin. 

Attention  has  been  called  by  Tom  A.  AVilliams-"  to  the 
similarity  of  many  of  the  manifestations  of  neurasthenia  to 
those  of  hypoadrenia.  Where,  in  a  neurasthenic,  subnormal 
blood-pressure  and  temperature,  together  Avith  pigmentary 
skin  changes,  are  noted,  hypoadrenia  should,  according  to  this 
author,  be  suspected  as  an  underlying  cause.  Treatment 
directed  toward  overcoming  this  condition  might  be  expected 
to  be  particularly  helpful  in  these  cases. 

In  the  hypoadrenia  of  old  age,  as  in  that  due  to  overbur- 
dening of  the  adrenals  at  any  period  of  life,  active  stimulation 
of  the  adrenals  by  drugs  is  unwise,  not  only  on  account  of  the 
possibility  of  accelerating  the  retrogressive  changes  in  these 
organs  through  excessive  functional  activity,  but  also,  in  the 
former  group  of  cases,  owing  to  the  frequent  coexistence  of 
arteriosclerosis.  Other  measures,  however,  can  be  utilized  to 
help  make  up  for  the  impaired  adrenal  function.  In  the  diet, 
milk,  a  product  in  which  the  adrenal  principle  is  present,  as 
shown  by  Sajous,  Sr.,  affords  a  ready  means  of  compensation. 


DISEASES    OF   THE    ADRENALS.  •J'J 

the  antitoxic  properties  of  milk,  for  example,  tending  to  re- 
place those  of  the  lacking-  adrenal  product.  Another  beneficial 
dietetic  measure  is  the  daily  ingestion,  in  addition  to  simple, 
though  varied,  food,  of  the  expressed  juice  (uncooked)  of  1 
pound  of  fresh  beef,  taken  alone  or  in  a  soup.  A  hygienic 
mode  of  living,  with  exercise  out-of-doors  in  reasonable 
amount,  and  marked  caution  in  sexual  matters — overindul- 
gence proving  very  debilitating  in  such  subjects — is  also  im- 
portant. In  the  presence  of  marked  general  asthenia,  adminis- 
tration of  adrenal  products  may  be  necessary.  Thus,  in  the 
case  of  a  lady  of  72  years,  confined  to  bed  through  sheer  weak- 
ness and  listlessness,  and  observed  by  Horton,28  adrenalin 
yielded  striking  results,  though  strong  tonics,  including  strych- 
nin, had  failed.  The  output  of  urine,  previously  reduced  to  10 
or  12  ounces  a  day,  rose  in  two  days  to  40  ounces,  and  in  a 
few  days  the  patient  was  up.  Continued  use  of  the  adrenalin 
proved  essential,  the  previous  debility  returning  whenever  the 
drug  was  temporarily  left  ofif.  Of  interest  in  relation  to  this 
case  is  the  experimental  observation  by  Marshall  and  Davis-*^ 
of  a  marked  lowering  of  renal  efficiency  in  adrenalectomized 
cats,  even  where  the  blood-pressure  had  not  yet  sunk  below 
normal. 

Terminal  Hypoadrenia,  This  term  has  been  applied  by 
Sajous,  Sr.,  to  the  form  of  adrenal  insufificiency  which  occurs 
late  in  the  course  of  an  acute  febrile  disease  as  a  result  of  ex- 
hausting functional  overactivity.  The  condition  of  the  ad- 
renals r^2Ly  have  been  aggravated  through  temporary  local 
lesions  induced  in  them  during  the  course  of  the  general  dis- 
ease. Pathologically,  adrenals  thus  affected  differ,  in  the 
majority  of  instances,  from  those  of  functional  hypoadrenia  in 
being-  not  only  enlarged  and  hyperemic,  sometimes  with  small 
areas  of  hemorrhage,  but  also  the  seat  of  a  passive  type  of 
cong'estion  due  to  loss  of  resiliency  of  their  sinus-like  vessels, 
with  consequent  impediment  to  the  circulation  through  the 
organs.  Suppuration  in  the  adrenals  is  at  times  also  a  com- 
plication in  the  presence  of  a  strepto-,  pneumo-,  or  meningo- 
coccic  infection  in  other  structures. 

The  exhaustion  of  the  adrenal  function  in  the  presence  of 
infections  probably  arises  from  the  fact  that  these  organs  are 
concerned  in  the  protection  of  the  organism  against  intoxica- 


78  DISEASES    OF    THE    DUCTLESS    GLANDS. 

tions  and  bacterial  invasions,  and  are  therefore  apt  to  be  func- 
tionally called  upon  to  a  marked  extent  in  the  presence  of 
disease.  Comessatti^'^  noted  that  in  diseases  of  long  duration 
the  epinephrin  content  of  the  adrenals  was  far  less  than  in 
cases  of  sudden  death.  In  typhoid  fever  and  diphtheria,  hypo- 
adrenia  is  observed  with  special  frequency.  Other  conditions 
in  which  it  has  been  noticed  by  various  authors  include 
lobar  and  bronchopneumonia,  septicemia,  scarlatina,  measles, 
mumps,  erysipelas,  acute  nephritis,  certain  forms  of  tonsillitis, 
etc.  Fulminating  or  malignant  types  of  the  acute  infections 
are  frequently  to  be  explained  on  the  basis  of  adrenal  insuffi- 
ciency, though  more  commonly  the  hypoadrenia  is  witnessed 
as  a  late  complication  after  a  period  of  gradual  exhaustion  of 
the  adrenals  from  continued  toxemia  has  elapsed.  The  mani- 
festations of  the  condition  are  similar  to  those  mentioned 
under  Functional  Hypoadrenia,  viz.,  unusual  asthenia,  circula- 
tor}^ weakness,  a  relatively  low  temperature,  vascular  hypoten- 
sion, chilliness,  pallor  and  Sergent's  white  line  phenomenon, 
together  with  anorexia,  nausea,  vomiting,  diarrhea,  a  tendency 
to  fainting  spells  or  sudden  exitus  from  cardiac  failure,  and  a 
liability  to  septic  complications  or  relapse  of  the  existing 
disease. 

Tscheboksaroff,-^!  tracing  experimentally  the  secretory 
activity  of  the  adrenals  in  animals  poisoned  with  diphtheria 
toxin,  noted,  as  we  might  expect,  at  first  an  increase  of  epi- 
nephrin in  the  blood,  followed  by  a  gradual  decrease  and  total 
disappearance.  From  the  pathological  standpoint,  IMoltscha- 
now^2  found  the  adrenals  regularly  the  seat  of  lesions  in  42 
children  succumbing  to  infectious  diseases,  including  29  cases 
of  diphtheria.  Beresnegowski^s  holds  acute  peritonitis  pre- 
eminent among  infections  in  the  production  of  adrenal  lesions, 
and  found  marked  histological  lesions  of  the  adrenal  cortex  in 
50  per  cent,  of  cases  examined  post-mortem.  Remlinger  and 
Dumas, ^^  observing  sudden  hypothermia,  and  heart  weakness 
in  4  out  of  100  soldiers  suffering  from  bacillary  dysentery, 
found  proof  at  the  autopsies  that  the  adrenals  had  been  the 
cause  of  these  symptoms.  Sergent'"^^  has  noted  hypoadrenia  in 
soldiers  as  a  result  of  traumatic  shock,  typhus  fever,  choleri- 
form  diarrhea,  Asiatic  cholera,  and  chloroform  anesthesia,  as 
well  as  of  physical  exhaustion. 


DISEASES    OF    THE    ADRENALS.  79 

Treatment.  Marked  benefit  has  been  noted  clinically  from 
adrenal  products  in  cases  presenting  thei  symptoms  above  re- 
ferred to.  In  emergency  cases,  administration  of  the  pure  prin- 
ciple epinephrin  is  advisable.  The  observations  of  Josue  (v. 
ante  under  Trejitment  of  Functional  Hypoadrenia)  and  others, 
have  established  the  efificacy  of  the  subcutaneous  and  oral 
routes  of  administration,  though  where  there  is  immediate  dan- 
ger, the  intravenous  route,  the  epinephrin  being  given  in  nor- 
mal saline  solution,  will  procure  even  more  prompt  results. 
Moizard^^  recommends  use  of  the  pure  principle  as  soon  as 
asthenia  and  low  blood-pressure  occur  in  any  infection,  and 
Kirchheim,^"  among-  others,  found  0.6  to  1.5  mils  (10  to 
24  m.)  doses  of  the  1 :  1000  solution  safe  when  given  hypoder- 
mically  in  the  collapse  of  pneumonia,  diphtheria,  and  scarlet 
fever.  Personal  observations  as  to  the  benefit  from  adrenalin 
in  adynamic  cases  of  typhoid  fever  and  other  acute  infections 
have  been  quite  convincing.  In  cardiovascular  failure  in  pneu- 
monia and  typhoid  and  paratyphoid  fevers,  Mansvetova^^ 
found  0.5  mil  (8  w.),  hypoderrrfically  every  hour  or  hour  and  a 
half,  the  best  dose  for  persistently  improving  the  blood-pres- 
sure. In  hypoadrenia  due  to  traumatic  shock,  infections,  ex- 
haustion, etc.,  Sergent"^  thinks  it  best  to  combine  oral  with 
hypodermic  use,  administering  2  to  3  milligrams  (%o  to  34o 
gr.)  of  the  pure'  principle  in  4  to  6  doses  hypodermically  and 
1  to  2  milligrams  (%o  to  %o  S^-)  orally. 

In  cases  in  which  the  advent  of  asthenia  and  low  blood- 
pressure  is  gradual,  dried  suprarenals  {Suprarenalum  siccmn. 
U.  S.  P.)  may  appropriately  be  given  by  mouth  in  doses  of 
0.1  to  0.3  gram  (1^  to  5  gr.)  in  capsules  three  times  a  day. 
According  to  Josue,40  hypodermic  use  of  a  suitable  preparation 
of  the  whole  gland  in  a  daily  dosage  of  0.1  gram  (1^  gr.) 
gives  good  results. 

The  combined  use  of  adrenal  and  pituitary  preparations  has 
been  specially  urged  in  the  circulatory  weakness  and  adynamia 
of  infectious  diseases'  by  Kepinow  and  others.  Rohmer,-*! 
in  the  hypoadrenia  of  pneumonia,  diphtheria,  and  typhoid  fever 
in  children,  claims  to  have  found  the  combined  intravenous  ad- 
ministration of  pituitrin,  0.25  mil  (4  m.),  and  adrenalin  solu- 
tion 0.5  mil  (8  m.),  in  young  children,  with  doses  twice  as 
large  in  older  children,  superior  to  other  circulatory  stimulants. 


80  DISEASES    OF   THE   DUCTLESS    GLANDS. 

After  cardiac  adynamia  has  passed  off  under  the  influence 
of  adrenal  therapy,  dried  thyroid  (Thyroideum  sic  cum,  U. 
S.  P.),  0.03  gram  {}4  gr.),  together  with  strychnin,  0.001 
gram  (%o  S^-)>  ^"d  Blaud's  pill-mass,  0.06  gram  (1  gr.),  may 
be  added  to  the  above-mentioned  capsules  of  dried  adrenal 
gland,  to  accelerate  convalescence. 

Chronic  Progressive  Hypoadrenia,  or  Addison's  Disease. 
The  symptoms  of  this  disorder,  generally  due  to  chronic  les- 
ions, often  tuberculous  and  occasionally  cancerous,  of  the  ad- 
renals, are  in  the  main  those  of  functional  hypoadrenia — al- 
ready summarized — with  certain  special  features  superadded. 
In  some  cases  the  adrenal  insufficiency  is  not  due  primarily  to 
disease  of  the  adrenal  tissues  themselves,  but  to  lesions  in, 
or  in  the  vicinity  of,  their  secretory  nerves,  whether  in  the 
ganglia  of  the  suprarenal  plexuses,  the  splanchnic  nerve- 
trunks,  or  the  spinal  cord  near  the  point  of  emergence  of  the 
adrenal  pathways.  Pressure  on  such  nervous  pathways  can 
doubtless  result  finally  in  interference  with  the  adrenal  func- 
tions, either  through  interruptibn  of  secretory  nerve  impulses 
or  through  primary  excitation  followed  by  lasting  exhaustion 
of  the  glandular  parenchyma.  In  cases  recorded  by  Semmola 
and  Brault,  for  example,  bronzing  occurred  through  protracted 
pressure  upon  the  semilunar  ganglia  and  solar  plexus. 

Lowered  temperature,  progressive  asthenia,  weak  heart- 
action,  low  blood-pressure,  and  dyspnea  are  manifest  results 
of  the  increasing  hypoadrenia.  Emaciation  through  deficient 
anabolism,  anorexia  through  lowered  demand  of  the  tissues 
for  their  pabulum,  vomiting  from  gastroptosis  and  deficient 
evacuatory  peristalsis,  and  constipation  through  intestinal 
atony  or  diarrhea  from  passive  congestion  of  the  mucosa,  are 
all  subsidiary  effects  of  the  underlying  adrenal  impairment. 
Sergent's  "white  line,"  a  broad,  white  streak  which  gradually 
appears  upon  drawing  a  finger  pulp  over  the  abdominal  skin, 
and  passing  away  after  three  or  four  minutes,  seems  to  be 
in  some  degree  a  diagnostic  sign.  The  general  impairment  of 
muscular  tone  and  consequent  asthenia  are  probably,  in  part 
at  least,  due  to  imperfect  carbohydrate  metabolism,  Macken- 
zie^^  having  found  a  diminution  of  the  power  to  form  glyco- 
gen from  glucose  in  adrenalectomized  dogs ;  sugar  adminis- 
tered to  such  animals  was  neither  oxidized  nor  stored  as  glyco- 


DISEASES   OF   THE   y\DRENALS.  81 

gen,  but  was  entirely  eliminated  as  such  in  tlie  urine.  The 
effect  of  a  general  lack  of  glycogen  on  motor  functions  is 
obvious. 

Thei  bronzing  of  Addison's  disease  is  not  an  essential 
symptom  of  the  condition,  some  cases,  in  fact,  dying  before  the 
pigmentation  has  appeared.  As  clinical  observations  and  ani- 
mal experiments  have  shown,  it  is  an  indication,  where  pres- 
ent, of  advanced  lesions  in  the  adrenals  or  of  their  nerve-sup- 
ply. As  a  rule,  it  occurs  only  in  the  course  of  a  gradual  im- 
pairment of  the  adrenals,  Brown-Sequard,  indeed,  having  al- 
ready noted  man}^  years  ago  that  it  appeared  particularly  in 
animals  in  which  operations  on  the  adrenals  were  so  performed 
as  to  cause  death  only  after  some  months.  Lippmann,^-'^  how- 
ever, has  reported  a  case  of  acute  Addison's  disease  in  a  pre- 
viously healthy  young  sailor,  in  which  low  blood-pressure,  in- 
tense asthenia,  signs  of  intoxication,  and  pigmentation  followed 
in  rapid  succession,  with  death  on  the  eighteenth  day. 

Other  common  manifestations  of  advanced  Addison's  dis- 
ease include  a  tendency  to  syncope  and  to  impairment  of 
vision  and  hearing,  due  to  ischemia  of  the  brain  and  special 
sense  structures,  and  a  toxemia,  due  to  deficient  antitoxic 
function,  finding  its  symptomatic  expression  in  headache,  irri- 
tability, muscular  twitchings,  delirium  and  convulsions. 
Death  may  occur  from  progressive  asthenia,  adrenal  apoplexy 
or  interstitial  hemorrhage  due  to  excessive  congestion  of  these 
organs  when  the  seat  of  advanced  lesions,  or  from  intercurrent 
disease. 

Treatment.  The  most  logical  procedure  in  chronic  disease 
of  the  adrenal  tissues  causing  impaired  function  is  obviously 
to  replace  the  missing  glandular  parenchyma  through  adrenal 
grafting.  The  numerous  attempts  made  at  experimental 
grafting  in  adrenalectomized  animals  have  been,  as  a  rule,  dis- 
appointing, thougih  Busch,  Leonard,  and  Wright'*'*  have  suc- 
ceeded in  transplanting  the  adrenal  of  a  rabbit  into  the  kidney 
of  another  rabbit  previously  subjected  to  unilateral  adrenalec- 
tomy, and  upon  removal  of  the  remaining  adrenal  after  thirty- 
six  days,  witnessed  recovery  of  the  animal,  indicating  func- 
tional activity  on  the  part  of  the  transplanted  organ.  Cases 
of  transplantation  of  an  animal  adrenal  into  a  human  subject 
sufferinof    from    Addison's    disease    have    often    resulted    dis- 


82  DISEASES    OF    THE    DUCTLESS    GLANDS. 

astrously,  however,  death  sometimes  following  within  one  or  a 
few  days.  A  reasonable  explanation  of  these  unfortunate  re- 
sults is,  however,  not  hard  to  find.  When  one  calls  to  mind 
that  less  than  one-tenth  of  the  average  total  amount  of  ad- 
renal tissue  with  which  the  organism  is  provided  has  been 
experimentally  shown  to  be  sufficient  to  satisfy  completely  the 
demands  on  adrenal  function  under  ordinary  conditions,  and 
that  upon  gradual  pathologic  destruction  of  the  adrenal  glands 
such  readjustments  of  function  may  occur  in  other  ductless 
glands  as  will  enable  the  organism  to  live,  for  a  time  at  least, 
with  even  less  than  one-tenth  of  the  normal  amount  of  ad- 
renal tissue  still  functionating,  it  is  obvious  that  the  addition 
of  an  excessive  amount  of  adrenal  tissue  to  the  system  may 
result  in  so  inordinate  an  adrenal  functional  effect  as  will  dan- 
gerously disturb  the  body  as  a  whole.  Such  a  condition  seems 
to  have  been  responsible  for  at  least  some  of  the  deaths 
promptly  following  clinical  adrenal  transplantation,  Cour- 
mont,45  for  example,  having  noticed  after  the  procedure  a 
'■'formidable  hyperthermia"  which  persisted  until  death  in  col- 
lapse in  spite  of  the  absence  of  all  signs  of  infection.  Evi- 
dently, in  grafting,  it  is  eminently  necessary  to  adjust  the  size 
of  the  graft  to  the  actual  needs  of  the  recipient,  remembering 
that  the  more  advanced  the  preceding  adrenal  destruction  the 
greater  is  likely  to  be  the  harmful  effect  of  a  large  addition  of 
adrenal  tissue.  The  occurrence  and  degree  of  such  an  effect 
may,  of  course,  be  expected  to  depend  upon,  and  vary  accord- 
ing to,  the  extent  of  absorption  of  the  adrenal  product  from 
the  new  adrenal,  as  well  as  the  rapidity  with  which  a  blood- 
supply  permitting  of  functional  activity  in  the  graft  is  de- 
veloped. 

In  what  appears  to  be  a  successful  case  of  adrenal  grafting 
reported  by  D.  M.  Morton,-*^  transplantation  of  an  adrenal  from 
a  patient  dead  of  heart  disease  was  effected  into  the  lower 
portions  of  the  recti  abdominis  muscles  in  a  woman  of  35 
with  typical  Addison's  disease,  deemed  of  tuberculous  origin. 
The  adrenal  transferred  was  bisected  and  one-half  buried  in 
each  rectus.  For  four  days  the  patient  was  very  ill,  but  there- 
after she  improved  rapidly,  and  was  soon  restored  to  com- 
paratively good  health,  with  a  distinct  lessening  of  pigmenta- 
tion and  rise  of  blood-pressure,  and  a  gain  of  16  pounds  in 


DISEASES    OE    THE    ADRENALS.  83 

weight.  This  case,  while  sufficiently  advanced  to  show  pig- 
mentation, was  from  the  symptomatology  not  as  yet  in  a 
critical  stage  of  adrenal  deficiency.  This  may  explain  the  rela- 
tive lack  of  an  alarming  reaction  after  transplantation  of  an 
entire  adrenal. 

Adrenal  transplantation  not  having  so  far  shown  its  avail- 
ability as  a  routine  measure,  reliance  is  usually  placed  on  ad- 
renal opotherapy  to  make,  good  the  deficiency  in  adrenal  func- 
tion. As  Sergent'*'^  has  stated,  Addison's  disease  can  often  be 
benefited,  and  sometimes  even  recovered  from,  through  this 
means.  The  treatment  tends  at  times,  indeed,  to  induce  a  com- 
pensatory hypertrophy  of  remaining  adrenal  tissue  which  will 
partially  eliminate  the  deficiency.  In  25  of  120  cases  collected 
by  E.  W,  Adams,'*^  permanent  benefit  accrued  from  such 
treatment.  That  careful  adjustment  of  the  dosage  to  the 
needs  of  the  individual  case  is  essential  is  illustrated  by  Bate's 
case,49  in  which  but  0.005  gram  (%2  S^-)  <^f  adrenal  gland 
three  times  a  day  caused  great  improvement,  with  temporary 
aggravation  when  the  drug  was  discontinued  for  a  time;  while 
in  a  case  reported  by  Suckling^o  the  daily  amount  was  grad- 
ually increased  from  0.6  to  12  grams  (10  to  175  gr.),  likewise 
with  benefit  resulting.  Failure  in  the  use  of  the  remedy  may 
thus  occur  either  from  excess  or  insufficiency  of  dosage.  Ad- 
renal gland  will  prove  helpful  when  adrenalin  will  fail,  as 
shown  by  Judson  Daland.^i 

As  guides  to  the  proper  dose,  records  of  the  temperature 
and  blood-pressure  are  convenient.  Where  both  are  consider- 
ably below  normal  0.2  gram  (3  gr.)  of  the  dried  gland  {Sxipra- 
renalum  siccum,  U.  S.  P.),  twice  daily  during  meals,  consti- 
tutes an  average  initial  dose,  to  be  increased  if  necessary,  to 
restore  the  temperature  and  blood-pressure  to  normal.  If  the 
dried  gland  be  not  available,  a  glycerin  extract  of  fresh  gland 
may  be  used,  or  fresh  sheep  or  ox  adrenals  given  twice  a  day 
in  doses  of  0.3  to  1  gram  (5  to  15  gr.).  It  should  be  borne  in 
mind,  as  regards  the  temperature,  that  in  many  instances  of 
Addison's  disease,  hypothermia  is  prevented  by  the  febrile 
reaction  attending  the  underlying  disorder  itself,  e.g.,  tuber- 
culous infection  or  carcinoma  and  the  coexisting  toxemia. 

Appropriate  remedies  other  than  dried  adrenal  include 
Blaud's  mass,  to  counteract  the  anemia;  glucose,  found  useful 


84  DISEASES    OF    THE    DUCTLESS    GLANDS. 

by  Pitres  and  Gautrelet-"'-  to  lessen  the  adynamia  and  sensa- 
tion of  fatigue;  creosote  carbonate,  0.3  gram  (5  gr.)  three 
times  daily,  in  the  tuberculous  cases,  with  or  without  iodids, 
and  mercury,  found  ven,-  effective  by  Gaucher  and  Gougerot-^-^ 
in  a  case  believed  due  to  syphilitic  involvement  of  the  adrenals. 
Proper  treatment  of  the  underlying  systemic  disorder,  where 
such  exists,  is,  of  course,  never  to  be  omitted.  In  a  case  re- 
corded bv  i\Iunro.^^  suspected  of  tuberculous  origin,  the  cus- 
tomarv  climatic  and  general  hygienic  procedures,  coupled  with 
courses  of  tuberculin  injections,  seemed  to  restore  the  patient 
to  good  health.  Indeed,  such  cases  should  always  receive 
treatment  addressed  to  the  tuberculous  process. 

Rest,  in  or  out  of  bed.  according  to  the  stage  of  the  case,  is 
indicated  owing  to  the  cardiac  weakness  and  tendency  to 
syncope.  The  diet  should  be  nutritious  but  readily  digested, 
milk  and  meats  being  especially  serviceable.  AMiere  motor 
adynamia  of  the  stomach  gives  trouble,  gastric  lavage  will 
give  relief.  If  diarrhea  exists,  bismuth  ma}^  appropriately  be 
given. 

Pituitary-  preparations,  probably  related  in  their  composi- 
tion and  eftects  to  the  adrenal  products,  may  prove  of  some 
value.  Unusual  caution  is  desirable  as  regards  the  intravenous 
administration  of  blood-pressure-raising  remedies,  especially 
the  adrenal  principle  itself,  Lown.-.-^^  for  example,  having  re- 
ported a  case  in  which  adrenalin  intravenously  caused  general 
sweating  followed  by  sudden  cardiac  and  respirator}-  arrest, 
with  recover}'  only  after  half  an  hour's  vigorous  artificial 
respiration. 

ADRENAL  OVERACTIVITY  (HYPERADRENIA). 

Considerable  experimental  evidence  is  at  hand  to  show 
that,  under  the  influence  of  various  bacterial  toxins,  inor- 
ganic poisons,  and  vegetable  drugs,  pronounced  congestion  of 
the  adrenals  may  be  produced.  Bernard  and  Bigart,^''  study- 
ing the  effects  of  arsenic,  mercury,  and  lead  on  the  adrenal 
parenchyma,  found  in  the  less  profound  intoxications  the  his- 
tological signs  of  functional  hyperactivity  of  these  organs  and, 
in  the  more  severe  intoxications,  destructive  lesions.  AV.  H. 
Brown  and  L.  Pearce-^"  deem  adrenal  injur}-  an  important  fac- 


DISEASES    OF    THE    ADRENALS.  85 

tor  in  arsenical  intoxication,  and  found  that  toxic  doses  of  all 
arsenicals  induced  adrenal  chang"es,  including-  cong^estion, 
hemorrhag'e,  disturbances  in  the  lipoid  and  chromaffin  content, 
and  cellular  degenerations  and  necroses.  In  the  presence  of 
bacterial  products,  congestion  of  the  adrenals  may  either  be 
dlie  to  the  participation  of  these  organs  in  the  defensive 
process,  the  accompanying  unusual  functional  activity,  in  con- 
junction with  a  like  state  in  the  thyroid  gland,  or  to  accumu- 
lation in  them  of  blood  resulting  from  high  general  vascular 
tension,  the  latter  sometimes  leading  to  focal  hemorrhages. 

The  adrenals,  furthermore,  are  peculiarly  subject  to  hemor- 
rhagic extravasations,  apparently  throug-h  fragility  of  their 
richly  distributed  vascular  tree  and  their  proximity  to  a  large 
arterial  trunk,  the  abdominal  aorta,  with  its  relatively  high 
level  of  blood-pressure.  Loeper  and  Oppenheim,'''^^  among  150 
autopsies  taken  at  random,  noted  five  instances  of  adrenal 
hemorrhage  visible  to  the  naked  eye,  and  eight  more  discern- 
ible microscopically.  In  cases  in  which  death  had  been  due 
to  infectious  disease,  the  ratio  of  adrenal  hemorrhages  was 
even  much  higher.  In  the  newborn,  adrenal  hemorrhage  is 
exceedingly  frequent,  45  per  cent,  of  250  autopsies  having 
shown  this  condition. 

Both  clinical  and  experimental  observations  indicate  that 
adrenal  congestion  occurs  as  a  precursor  of  adrenal  hemor- 
rhage. Hence,  the  fact  that  where  adrenal  congestion  due  to 
increased  functional  demands  on  these  organs  exceeds  a  cer- 
tain limit,  adrenal  hemorrhage  will  result,  especially  in  the 
presence  of  such  blood-pressure  conditions,  e.g.,  a  toxic  hyper- 
tension, as  will  impose  an  unusual  centrifugal  stress  on  the 
adrenal  vessels. 

In  the  newborn,  adrenal  hemorrhage  may  occur  within  a 
few  moments  or  days  after  birth,  and  entail  sudden  death., 
Apparently  any  condition  tending-  to  interfere  with  proper  in- 
itiation of  the  respiratory  function  predisiposes  to  it.  Cyanosis, 
purpuric  spots,  convulsions,  and  death  constitute  the  clinical 
course  of  events  in  such  instances..  In  another  group  of  cases 
the  condition  seems  due  to  incapacity  on  the  part  of  the  de- 
fensive resources  of  the  infant,  perhaps  through  lack  of  the 
immunizing  constituents  of  maternal  milk  to  cope  wth  some 
endogenous  toxemia.    The  accumulating  toxic  wastes,  causing 


86  DISEASES    OF    THE   DUCTLESS    GLAXDS. 

a  violent  elevation  of  the  blood-pressure  in  adrenals  already 
congested  through  hyperactivity,  break  down  the  resistance  of 
one  or  more  adrenal  vessels,  and,  rupturing-  them,  lead  to 
hemorrhage  and  such  clinical  manifestations  as  abdominal 
pain,  diarrhea,  vomiting,  and  increasing  coldness  of  the  ex- 
tremities, followed  by  convulsions  or  cardiac  collapse. 

In  children,  a  verv  similar  train  of  events,  with  death  in 
from  a  few  to  forty-eight  hours  after  adrenal  hemorrhage,  is 
produced  from  the  action  of  various  infectious  conditions,  in- 
cluding the  exanthemata,  diphtheria,  septic  processes,  bron- 
chopneumonia, etc..  as  well  as  from  ptomaine  poisoning,  ex- 
tensive burns,  or  other  severe  injuries.  Venous  stasis  and  a 
marked  increase  of  the  blood-pressure  are,  according  to  Dud- 
geon,-5^  frequently  associated  conditions.  Fever  and  high 
blood-pressure  in  any  infection  should  suggest  the  possibility 
of  adrenal  hemorrhage. 

In  adults  sudden  or  rapid  death  from  adrenal  apoplexy  is 
not  as  uncommon  as  is  generally  believed.  jMarked  abdom- 
inal pain,  radiating  to  the  back;  tympanites,  vomiting,  pros- 
tration, and  obstinate  diarrhea  are  the  clinical  features  of  this 
accident.  Purpura  is  far  less  common  than  in  children,  but  a 
vellowish  skin  discoloration,  passing  even  into  the  bronzing  of 
Addison's  disease,  is  not  infrequently  noted.  Epileptic  seiz- 
ures, unusual  physical  eftorts.  and  acute  nephritis  have  been 
known  to  bring  on  adrenal  hemorrhage  in  adults.  A  common 
characteristic  is  the  presence  of  pre-existing  adrenal  lesions, 
e.g..  tuberculous  changes,  which  predispose  the  adrenal  vessels 
to  rupture  when  any  added  strain,  such  as  a  rise  in  blood- 
pressure  due  to  toxic  accumulations,  is  imposed.  Arterio- 
sclerosis involving  adrenal  vessels  has  also  been  found  a  fac- 
tor predisposing  to  hemorrhage.  No  mention  of  adrenal 
hemorrhage  being,  in  general,  made  in  textbooks,  the  con- 
dition has  been  mistaken  clinically  for  arsenical  and  other 
forms  of  poisoning,  cholera  morbus,  appendicitis,  cerebral 
apoplexy,  etc. 

TREATMENT. 

In  view  of  the  wide  variety  of  possible  causes  of  hyper- 
adrenia  and  adrenal  hemorrhage,  and  the  consequent  mul- 
tiplicitv   of  symptoms  which   may   precede   it,   recognition   of 


Diseases  of  the  adrenals.  87 

the  condition  before  the  advent  of  actual  adrenal  injury  is  a 
difficult  matter.  High  blood-pressure  being,  however,  a  fre- 
quent determining  cause  of  the  hemorrhage,  where  this  con- 
dition is  observed  measures  may  be  taken  to  diminish,  by 
lowering  the  blood-pressure,  the  likelihood  of  serious  adrenal 
damage.  Thus,  such  drugs  as  veratrum  viride,  chloral  hydrate, 
nitroglycerin,  or  even  amyl  nitrite  may  be  administered,  ac- 
cording to  indications.  Preferable  to  any  of  these,  perhaps,  is 
saline  solution,  given  by  rectum  in  cases  of  possible  adrenal 
hemorrhage,  subcutaneously  in  threatening  cases,  or  intra- 
venously in  emergency  cases.  Exerting  a  detergent  action  on 
the  blood,  and  accelerating  elimination  of  toxic  materials 
through  the  kidneys,  saline  solution  tends  indirectly  to  allay 
toxic  spasm  of  the  vascular  system,  and  will  thus  effectually 
assist  in  obviating  excessive  stress  on  the  adrenal  circulation. 
Where  adrenal  hemorrhage  has  already  occurred,  evidences  of 
a  sudden  hypoadrenia  a,re  sometimes  to  be  noted.  The  treat- 
ment then  applied  should  be  that  of  terminal  hypoadrenia 
(q.z^.).  If  the  hemorrhagic  focus  is  not  so  large  and  destruc- 
tive as  immediately  to  endanger  life,  adrenal  or  pituitary^  prep- 
arations may  prove  of  marked  assistance  in  tiding  the  patient 
over  the  critical  period. 

ADRENAL  HEMATOMA. 

This  condition,  sometimes  termed  "adrenal  hemorrhagic 
pseudocyst,"  is  merely  a  complication  of  adrenal  hemorrhage, 
and  is  generally  unilateral.  It  may  cause  a  fatal  termination 
if  rupture  of  the  cyst  occurs,  its  contents  entering  the  peri- 
toneal cavity.  The  cyst  is  not  of  sudden  advent,  however,  but 
develops  gradually,  the  adrenal  tissues  becoming  destroyed  and 
transformed  by  it  so  that  its  contents  comprise  not  only  blood, 
but  cellular  detritus,  cholesterin  crystals,  etc.,  with  shreds  or 
remnants  of  the  adrenal  cortex  lining  its  walls.  While  such 
a  cyst  may  attain  a  large  size,  the  fact  that  the  opposite  ad- 
renal remains  uninvolved  practically  excludes  the  production 
of  symptoms  of  altered  adrenal  function,  the  signs  of  the  tumor 
being  merely  a  sensation  of  weight  and  pain,  due  to  pressure 
on  surrounding  sensitive  structures.  Subsequently,  the  pa- 
tient may  suddenly  begin  to  fail,  losing  weight,  and  develop- 


88  DISEASES    OF    THE    DUCTLESS    GLAXDS. 

ing  dyspnea,  polyuria,  hematuria,  and  even  slig"ht  bronzing. 
The  termination  is  usually  through  rupture  into  the  abdominal 
cavity. 

TREATMENT. 

Excision  of  the  affected  adrenal  is  the  procedure  of  choice, 
the  remaining  organ  sufficing  to  carr\-  on  the  adrenal  func- 
tions. Either  a  lumbar  or  an  anterior  abdominal  incision  may 
be  used.  Ordinarily,  an  oblique  incision  below  the  last  rib 
is  most  convenient,  or  if  much  space  is  required,  the  last  rib 
may  be  removed.  At  times  the  adrenal  cyst  adheres  so  tightly 
to  the  kidnev  that  the  latter  has  also  to  be  taken  out.  Kiitt- 
ner^^  has  reported  a  case  in  which  removal  of  the  cyst,  ad- 
herent to  adjacent  organs,  was  facilitated  by  tapping,  a  quart 
of  brownish  fluid  being  thus  evacuated ;  recover}'  followed. 
Among  11  cases  of  adrenal  cyst  found  by  him  in  the  literature, 
5  recovered. 

HYPERNEPHROMA. 

This  is  a  special  type  of  tumor  presenting  microscopically 
the  characteristic  features  of  the  adrenal  cortex,  and  develop- 
ing from  bits  of  adrenal  tissue-^adrenal  rests — either  in  the 
adrenals  themselves  or  in  the  walls  of  blood-vessels  or  other 
structures.  They  are  especiallv  common  in  the  kidney,  con- 
stituting, according  to  Albarran  and  Joubert,  17  per  cent,  of 
all  renal  tumors.  Less  often  they  occur  in  the  uterus,  ovary, 
broad  ligament,  etc..  from  adrenal  rests  therein.  Benign  at 
first,  they  gradually  exert  pressure  symptoms  in  surrounding 
structures,  and  later  tend  to  metastasize  in  the  lungs,  bones, 
and  brain. 

Hj-pernephroma  of  the  adrenals  develops  generally  between 
the  first  and  eighth  years,  and  causes  a  curious  form  of  pre- 
mature development,  as  a  result  of  which  the  child  may  ap- 
pear twice  or  three  times  its  actual  age.  Observed  usually  in 
girls,  the  condition  is  characterized  by  an  abundant  growth  of 
hair  over  the  face,  genitalia,  pubis,  and  sometimes  over  the 
entire  body,  with  a  swarthy  or  coppery  hue  of  the  skin.  The 
externa]  genitalia  often  show  a  marked  degree  of  precocity,  the 
voice  is  apt  to  be  deep  and  harsh,  muscular  strength  is  unusu- 
allv  well  developed,  and  the  body  is  obese.     The  effect  of  the 


DISEASES    UE    THE    ADRENALS.  89 

excess  of  adrenal  tissue  is  evidently  such  in  these  cases  as  to 
accelerate  growth  in  g"eneral,  though  the  actual  gigantism  and 
peculiar  facial  and  other  deformities  of  acromegaly  are  lack- 
ing. xAccordin^  to  Glynn  and  Hewetson/>i  abnormal  sex 
characters  do  not  develop  where  adrenal  hypernephroma  de- 
velops after  the  menopause,  and  are  probably  absent  in  adult 
males. 

In  hypernephroma  of  the  kidney,  hematuria  is  the  most  con- 
stant and  often  the  hrst  S3'mptom.  The  bleeding  occurs  inter- 
mittently, but  is  severe  while  it  lasts.  It  may  precede  the  de- 
velopment of  a  palpable  tumor  by  a  considerable  period.  Lum- 
bar pain  suggesting-  lumbago  may  also  at  times  be  the  initial 
symptom ;  or  metastasis  in  the  A'ertebrge,  ribs  or  other  long 
bones,  skull,  scapula,  etc.,  or  in  the  lung"s,  may  first  indicate 
the  condition.  Premature  arteriosclerosis  and  hig^h  blood-pres- 
sure may  be  observed,  and  the  skin  is  ts^pically  yellowish  or 
smoky  in  appearance.  According*  to  Gelle,  fragments  of  the 
tumor  may  be  found  in  clots  passed  per  urethram.  Confusion 
of  it  with  an  enlarged  spleen  is  obviated  in  that  it  usually  oc- 
curs on  the  rig^ht  side,  and  is  less  superficial  and  movable.  It 
is  distinguished  from  renal  calculus  in  that  the  pain  attending 
it  continues  after  the  hemorrhage.  The  duration  of  the  dis- 
ease is  from  fifteen  weeks  to  eight  years,  the  later  stages  being 
marked  by  emaciation,  weakness,  secondary  anemia,  edema 
from  pressure  on  a  vein,  delirium,  and  coma. 

Considerable  diagnostic  value  has  been  attributed  by  Israel, 
Neu,  and  others  to  the  presence  of  fever  during  the  early  stage 
of  hypernephroma,  before  cachexia  has  developed. 

TREATMENT. 

Since  hypernephromas,  upon  beginning  to  metastasize  or 
show  other  signs  of  malignancy,  are  likely  to  progress  rapidly, 
operative  exploration  of  the  abdomen  is  warranted  even  where 
their  presence  is  only  surmised,  viz.,  where  hematuria  and  an 
abnormal  growth  in  the  abdomen  in  the  kidney  region  coexist. 
The  mere  fact  that  a  hemorrhage  into  the  bladder  cannot  be 
accounted  for  constitutes,  according  to  many,  an  indication  for 
exploraton,^  incision  for  hypernephroma.  At  times  a  sensa- 
tion of  tension  or  discomfort  experienced  by  the  patient  over 
one  kidney,  or  deep  palpation  of  the  two  sides,  will  aft'ord 


90  DISEASES    OF    THE    DUCTLESS    GLANDS. 

guidance  as  to  which  side  should  be  explored  first.  In  excising 
the  growth,  the  fatty  capsule  should  also  be  removed,  accord- 
ing to  Kusniik,  recurrence  being  othenvise  a  possibility  from 
malignant  infiltration  of  the  fat.  By  incising  in  the  lumbar 
region  the  growth  may  be  removed  extraperitoneally. 

TUMORS  OF  THE  ADRENAL  BODIES. 

Malignant  Tumors.  Malignant  hypernephroma,  though 
common  in  the  kidneys,  is  rare  in  the  adrenals  themselves, 
the  chief  primar}'  malignant  tumors  of  the  adrenals  being  car- 
cinoma and  sarcoma,  which  occur  with  approximately  equal 
frequency.  The  former  occurs  usually  in  adult  and  aged  sub- 
jects; the  latter,  in  early  life.  In  each,  the  clinical  course  is 
characterized  by  gradual  emaciation  and  increasing  adynamia, 
with  enfeebled  cardiac  action,  anorexia,  digestive  disturbances, 
anemia,  and  occasionally  respiratory  complications.  In  the 
majority  of  cases,  various  degrees  of  the  skin  pigmentation 
typical  of  Addison's  disease,  ranging  from  slight  yellow^ness  to 
actual  bronzing,  are  to  be  noted.  According  to  Israel,^^  two 
symptoms  are  of  special  diagnostic  import,  signifying  adrenal 
involvement:  (1)  paroxysms  of  pain  and  paresthesias  in  the 
absence  of  a  palpable  tumor,  and  (2)  a  febrile  course,  noticed 
by  this  observer  in  57  per.  cent,  of  his  cases,  whereas  in  renal 
tumors  it  was  noticed  only  in  1  to  2  per  cent.  The  early  pain 
is  due  to  extension  of  the  growth  to  the  closely  adjoining 
roots  of  the  lumbar  plexus. 

The  febrile  tendenc}^  in  the  earlier  stages  of  the  disease, 
and  the  hypothermia  usual  in  advanced  cases,  together  with 
the  various  other  symptoms  already  enumerated,  seem  to  point 
directly  to  a  primary  excitation  by  the  growth,  followed  by 
impairment,  of  the  adrenal  functions  relating  to  oxidation  and 
tissue  metabolism,  according  to  the  conception  of  these  func- 
tions introduced  by  Sajous,  Sr. 

After  emaciation  and  adynamia  have  been  progressive  for 
some  time,  a  mass  can,  as  a  rule,  be  discovered  by  palpation 
posteriorly  below  the  ribs.  In  infants,  however,  there  may  be 
noticed  merely  a  gradual  enlargement  of  the  abdomen  with  an 
increasing  area  of  dullness.  In  long-standing  cases,  edema 
(the  result  of  pressure  on  vessels)  may  be  noted. 


DISEASES    OF    THE    ADRENALS.  91 

On  the  borderline  between  benign  and  mab'gnant  growths 
of  the  adrenals  are  the  paragangliomas  or  chromaffin  tumors, 
developing,  in  the  medulla  of  the  adrenals  or  the  carotid 
glands.  J.  S.  Dunn/*-"  moreover,  has  collected  from  the  litera- 
ture 51  cases  of  adrenal  ganglioneuroma,  a  malignant  tumor 
developing  either  in  the  adrenals  or  the  sympathetic  nerve  tis- 
sues. His  own  case,  that  of  a  boy  aged  14,  succumbed  after  a. 
three  months'  illness  featured  by  wasting,  pain  in  the  back, 
ascites,  and  marked  hepatic  enlargement. 

Treatment.  The  results  of  operative  work,  where  removal 
of  the  growth  is  attempted,  are  apt  to  be  unsatisfactory,  the 
diagnosis  being,  as  a  rule,  made  only  at  an  advanced  stage, 
when  metastasis  has  occurred.  If  one  should  succeed  in  oper- 
ating sufficiently  early  to  remove  the  entire  disease  focus,  the 
opposite  adrenal,  remaining  unaffected,  would  doubtless  prove 
adequate  in  maintaining  the  adrenal  functions.  Where,  in  ad- 
vanced cases,  these  functions  have  been  so  impaired  as  to  give 
rise  to  the  syndrome  of  Addison's  disease,  treatment  with  ad- 
renal and  other  products,  as  described  under  Hypoadrenia 
(q.v.),  might  temporarily  prove  of  distinct  service. 

Benign  Tumors.  Among  the  recorded  types  of  benign 
tumors  of  the  adrenals,  other  than  mere  hyperplasias,  are 
adenoma,  fibroma,  lipoma,  angioma,  and  echinococcic  cyst. 
Michon^'*  has  reported  the  case  of  a  man  of  62  in  whom  post- 
mortem, a  large  adenoma  of  the  left  adrenal  was  noted.  In  life, 
nothing  had  been  noticed  save  the  presence  of  a  tumor  in  the 
left  hypochondrium  and  a  marked  increase  in  urea  excretion  in 
the  urine — the  latter  condition  probably  a,n  illustration  of  the 
important  influence  of  the  adrenals  on  general  metabolism.  In 
many  instances,  benign  adrenal  tumors  exert  a  peculiar  influ- 
ence on  the  sex  characteristics,  particularly  inducing  in  female 
subjects  changes  tending  toward  what  Tuffier^^  terms  "ad- 
renal virilism."  Thus,  a  woman  of  62,  in  whom  a  large  fibro- 
lipoma  of  the  adrenals  was  noted  at  the  autopsy,  had  developed 
during  life — since  the  age  of  30 — a  thick  black  beard  and 
moustache,  a  masculine  face  and  voice,  great  muscular  power, 
a  fondness  for  hard  manual  labor,  etc.,  and  the  clitoris  had  be- 
come so  enlarged  as  to  resemble  a  penile  organ.  A  similar 
case  of  hermaphroditism  due  to  an  adenoangiolipoma  of  the 
left   adrenal   which    had   attained   the   size   of  a   cocoanut   is 


92  DISEASES    OF    THE    DUCTLESS    GLANDS. 

described  by  Auvray.'^*^  Bourcy  and  Legueu/J"  operating  for 
a  large,  painful,  left-sided  abdominal  tumor  in  a  woman  of  61, 
found  a  lymphangiomatous  adrenal  cyst  holding  5  liters  of 
fluid  practically  surrounding  the  left  kidney.  As  regards  hy- 
datid cysts,  Nicaise,*^^  among  10,000  cases  of  this  form  of 
parasitism,  found  post-mortem  6  cases  of  cystic  involvement 
of  the  adrenals ;  in  none  of  these  had  evidences  of  adrenal  im- 
pairment been  noticed  during  life. 

Treatment.  This  consists  of  excision  for  pressure  symp- 
toms, and  the  use  of  adrenal  products  and  other  indicated 
remedies  where  adrenal  insufficiency  results  from  bilateral 
involvement. 

DISEASES  OF  THE  THYROID  GLAND. 

Developing  as  a  bud  from  the  pharynx,  which,  in  turn, 
grows  downward  from  the  .posterior  portion  of  the  tongue  into 
the  neck,  the  thyroid,  in  its  completed  state,  consists  of  a 
median  isthmus  and  two  lateral  lobes  that  the  isthmus  unites 
just  below  the  level  of  the  cricoid  cartilage.  The  surgical  cap- 
sule of  the  gland,  a  process  of  the  deep  cervical  fascia,  holds  it 
in  close  apposition  to  the  trachea,  this  anatomical  feature  ac- 
counting- for  the  rise  of  the  gland  during  the  act  of  swallowing 
and  the  ease  with  which  the  trachea  can  be  seriously  com- 
pressed and  deformed  in  the  presence  of  thyroid  enlargement. 

Apart  from  the  so-called  pyramidal  lobe  of  the  thyroid — 
an  anomalous  mass  of  thyroid  tissue  which  sometimes  de- 
velops from  the  thyroglossal  duct — accessory  lobes  may  occur 
anywhere  in  a  triangular  area  with  its  base  at  the  margin  of 
the  lower  jaw  and  its  apex  at  the  root  of  the  aorta,  and  gi"^e 
rise  to  retrosternal  goiters. 

The  thyroid  tissue  is  composed  essentially  of  vesicles  of 
different  sizes,  lined  with  a  single  layer  of  cylindrical  or  cubical 
cells.  These  vesicles  contain  a  characteristic  colloid  material  in 
which  the  supposed  physiologically  active  thyroid  constituent, 
iodothyrin,  is  embodied.  The  gland  being  ductless,  its  inter- 
nal secretory  product  has  been  thought  to  pass  into  the  blood 
from  the  lymphatics  surrounding  it,  the  vesicles  presumably 
rupturing  to  discharge  the  colloid  material  into  the  lymph- 
spaces.     Although  doubt  persists  as  to  the  precise  route  and 


DISEASES   OF   THE   THYROID.  93 

rate  of  absorption  or  discharge  of  the  colloid,  it  is  neverthe- 
less established  that  stored  colloid  may  be  dissipated  from  the 
gland  in  a  relatively  short  time,  and  that  for  months  the  organ 
may  then  remain  practically  deprived  of  visible  colloid.  Ac- 
cording- to  Bensley,^^  a  "secretion  antecedent"  of  the  thyroid 
occurs  in  vacuoles  in  the  outer  poles  of  the  cells  lining  the 
vesicles,  and  consists  of  a  solution  having  properties  similar 
to  those  of  the  colloid  in  the  vesicles,  but  more  dilute,  and 
ready  in  the  outer  portions  of  the  lining  cells  to  be  transported 
into  the  vascular  channels.  The  vesicle  contents,  according  to 
this  observer,  who  studied  the  structure  of  the  thyroid  as 
modilied  by  diet  and  drug's,  are  the  result  of  a  second,  indirect 
type  of  secretion  in  which  the  gland  products  are  condensed 
into  droplets  having-  a  high  content  of  solids  and  then  extruded 
into  the  lumina  of  the  vesicles  to  be  stored  for  future  use 
when  required.  Lack  of  colloid  in  a  given  thyroid  thus  does 
not  necessarily  signify  a  permanent  incapacity  to  secrete,  but 
rather  a  depletion  of  the  stored  material  for  the  time  being. 
Scanty  in  young  children  and  in  parenchymatous  goiter,  the 
colloid  is  unusually  abundant  in  exophthalmic  goiter.  The 
amount,  it  is  stated,  varies  also  according  to  the  locality  in 
which  the  subject  resides. 

Removal  of  the  thyroid  causes  pronounced  morbid  effects, 
but  these  have  been  found  to  vary  according  to  whether  the 
parathyroids  are  simultaneously  removed  or  allowed  to  re- 
main. The  difference  in  the  results  of  thyroidectomy  in  car- 
nivora  and  in  herbivora  was  shown  by  Gley  in  1892  to  be 
due  to  the  fact  that  whereas  in  the  latter  two  or  more  of  the 
parathyroids  are  anatomically  separate  from  the  thyroid  and 
hence  are  not  removed  in  thyroidectomy,  in  the  latter  all  the 
parathyroids  are  so  imbedded  in  the  thyroid  as  to  be  spared 
only  by  dint  of  special  care.  Excision  of  the  thyroid  gland 
alone,  as  Gley  showed,  does  not  necessarily  cause  death.  The 
morbid  phenomena  it  induces  are  especially  severe  in  young 
animals,  growth  being  arrested,  the  bones  and  epiphyseal  car- 
tilages failing  to  develop,  the  abdomen  becoming  protuberant, 
and  enlargement  of  the  sexual  glands  arrested.  Mental  de- 
velopment is  likewise  markedly  obtunded,  the  skin  is  rough, 
the  hair  becomes  coarse,  shaggy,  and  lustreless,  and  the  animal 
dies   after   a   more   or   less   prolonged '  period   of   progressive 


94  DISEASES    OF    THE    DUCTLESS    GLANDS. 

cachexia.  In  adult  animals,  no  effects  of  exclusive  thyroidec- 
tomy on  stature  are  apparent,  growth  having-  already  been 
completed,  but  marked  changes  are  nevertheless  manifest,  viz., 
impaired  general  nutrition  and  emaciation,  anemia,  coarseness 
of  the  skin,  falling  of  the  hair,  hypothermia,  etc.  All  these 
changes  are  aggravated,  in  the  female  sex,  by  pregnancy  and 
lactation. 

Removal  of  the  parathyroids,  alone  or  in  conjunction  with 
thyroidectomy,  causes  early  death,  and  substitutes  for  the 
more  gradually  developing  symptomatology  of  the  latter  oper- 
ation a  group  of  nervous  phenomena  characterized  by  a  tend- 
ency to  spasm  and  convulsions.  These  disturbances  range 
from  tetany  to  violent  tetanic  or  epileptoid  seizures.  Death 
takes  place  from  cramp  asphyxia  or  exhaustion,  usually  in 
from  three  to  five  days.     (See  Diseases  of  the  Parathyroids.) 

Of  interest,  further,  in  comparison  with  the  effects  of 
thyroidectomy  are  those  of  an  excess  of  thyroid  product. 
As  shown  by  Ewald,  Fenw^ick,  Haskovec,  and  many  others, 
such  an  excess  induces  tachycardia,  nervousness,  rapid  loss 
of  weight,  vasodilatation,  diuresis,  polydipsia,  polyphagia, 
polypnea,  glycosuria,  hyperthermia,  and  excessive  excretion  of 
nitrogenous  wastes,  eventually  followed  by  extreme  depres- 
sion, anorexia  and  vomiting,  loss  of  reflexes,  paralyses,  con- 
vulsions, and  death.  From  the  nature  of  the  effects  in  the 
earlier  stages,  coupled  with  numerous  related  clinical  and  ex- 
perimental observ^ations,  the  conclusion  can  hardly  be  escaped 
that  the  thyroid  physiologically  exerts  an  important  influence 
on  general  metabolism  and  nutrition.  That  this  is  actually  the 
case  is  clearly  illustrated  by  recent  accurate  determinations  of 
the  basal  metabolism,  which  has  been  shown  to  be  increased  in 
hyperthyroidism  to  a  degree  unattained  in  any  other  morbid 
condition,  and  correspondingly  decreased  in  hypothyroidism. 

The  precise  nature  of  the  active  substance  present  in  the 
thyroid  has  been  the  subject  of  painstaking  investigations  for 
many  years.  Baumann  in  1895  announced  the  discovery  of  an 
organic  iodin  compound,  Avhich  he  termed  iodothyrin,  as  the 
chief  principle  secreted  by  the  gland.  Later,  however,  Oswald, 
on  the  basis  of  careful  observations,  found  reason  to  deny 
Baumann's  view,  and  Avas  led  to  describe  the  true  thyroid 
principle    as    an    iodized    globulin,    termed   by   him    iodthyro- 


DISEASES   OF   THE   THYROID.  95 

g-lobuHii.  More  recently,  E.  C.  Kendall,  of  the  Mayo  Clinic, 
has  isolated  from  the  gland  a  crystalline  substance  containing 
no  less  than  60  per  cent,  of  iodine,  and  possessing-  the  physio- 
logic activity  of  the  g"land  itself.  Preliminary  work  directed 
toward  a  determinaton  of  the  structural  formula  of  this  sub- 
stance— termed  by  Kendall  the  alpha  iodin  compound  of  the 
thyroid — made  it  appear''*^  to  be  carbonic  acid,  in  which  one 
of  the  hydrogen  atoms  is  replaced  by  diiodo-indol.  The  ab- 
sorption of  iodin  by  the  thyroid  and  its  elaboration  into  the 
thyroid  hormone  have  been  subjects  of  interesting-  experimen- 
tal studies  by  David  Marine  and  his  co-workers.  Marine'''^ 
observed  that  living"  thyroid  tissue  has  an  extremely  pro- 
nounced affinity  for  iodin,  which  is  rapidly  taken  up  by  the 
gland  in  whatever  form  and  by  whatever  method  it  is  adminis- 
tered. The  amount  of  iodin  taken  up  was  found  to  vary,  not 
only  according  to  the  size  of  the  gland,  but  also  according  to 
the  existing  degree  of  thyroid  hyperplasia  and  the  degree  of 
saturation  of  the  thyroid  with  iodin  at  the  time.  With  J.  M. 
Rogoff,  the  same  experimenter'^^  found  that  while  the  storage 
of  iodin  in  the  thyroid  from  potassium  iodid  is  practically 
instantaneous,  transformation  into  the  specific  hormone  is 
much  slower,  only  a  small  fraction  of  the  iodin  taken  up  hav- 
ing been  thus  transformed  after  thirty  hours. 

That  nervous  influences  are  capable  of  markedly  exciting 
secretory  activity  on  the  part  of  the  thyroid  seems  to  have 
been  definitely  demonstrated  by  W.  B.  Cannon  and  McKeen 
Cattell,'''^  who  studied  the  activity  of  the  gland  through  the 
attending  electrical  changes  by  means  of  the  string  galvano- 
meter. The  sympathetic  system  proved,  in  fact,  to  be  a  con- 
trolling- factor  in  regulating  thyroid  activity,  as  Sajous,  Sr., 
urged  as  far  back  as  1903.  Adrenalin,  moreover,  was  found 
to  cause  "quite  remarkable  action  currents,"  and  stimulation 
of  the  splanchnic  nerve  indirectly  activated  thyroid  secretion 
by  causing  a  discharge  of  adrenalin  from  the  suprarenal 
glands. 

The  potent  influence  of  the  thyroid  secretion  on  general 
metabolism,  long  ago  pointed  out  by  Sajous.  Sr.,'^-^  with  ample 
proof  in  support,  raises  a  question  as  to  precisely  how  this 
metabolic  influence,  evidently  due  to  Kendall's  alpha  iodin 
compound,  is  exerted.     Plummer,  quoted  by  Kendall,"'*  from 


96  DISEASES    OF   THE   DUCTLESS    GLANDS. 

an  extended  clinical  study  of  thyroid  disturbances  in  several 
thousand  cases,  has  been  led  to  conclude  that  the  effects  of 
these  disturbances  are  due,  not  to  perverted  function,  but  to 
altered  rate  of  normal  function ;  that  the  stimulating  effect 
of  increased  thyroid  activity  is  not  limited  to  certain  organs 
or  tissues,  but  is  active  throughout  the  body,  and  furthermore 
that  the  stimulating  effect  is  intracellular.  The  senior  writer 
of  this  article"^  was  from  the  first  led  to  recognize  that  the 
combined  iodin  of  the  th3'roid  secretion  acts  by  rendering  "the 
phosphorus  of  all  tissue-cells,  and  particularly  their  nuclei, 
more  prone  to  undergo  oxidation  by  the  adrenoxidase  of  the 
blood."  Chittenden"'''  had,  indeed,  emphasized  "the  apparent 
connection  between  the  thyroid  gland  and  phosphoric  acid 
metabolism,"  pointing  out  the  increased  excretion  of  P2O5 
upon  feeding  thyroid  extracts  to  animals  and  the  marked  de- 
crease after  thyroidectomy.  The  striking  eft'ects  of  thyroid 
excess  on  the  nervous  SA-stem  also  constitute  evidence  in  this 
direction,  and  the  rapid  loss  of  fat  after  thyroid  administration 
in  the  obese  is  also  thus  explainable  from  the  presence  in  the 
fat-cells  of  nuclei  rich  in  phosphorus,  the  purpose  of  which 
is  to  promote  prompt  oxidation  of  the  stored  fat  when  the 
organism  requires  such  additional  oxidation. 

Sajous,  Sr.,  as  previously  shown  in  these  pages,  has  as- 
cribed the  influence  of  the  thyroid  on  oxidation  in  part  to  an 
influence  of  the  adrenals,  calling  attention  to  the  numerous 
points  of  similarity  in  the  symptoms  of  hypothyroidism  and 
hypoadrenia,  and  in  the  secreted  products  themselves.  Of  in- 
terest in  respect  to  oxidation  through  the  thyroid  are  the  con- 
firmation by  Youchctchenko"^  of  the  presence  of  catalases  and 
an  oxidizing  ferment  in  the  thyroid,  both  of  which,  moreover, 
he  found  also  in  the  red  blood-corpuscles;  the  finding  by 
Albertoni  and  Tizzoni'''^  that  thyroidectomy  leads  to  decreased 
power  to  fix  oxygen  on  the  part  of  the  blood,  and  the  observa- 
tion of  Masoin^o  that  the  relative  amount  of  oxyhemoglobin 
in  the  blood  gradually  lessens  after  the  same  operative  pro- 
cedure. ]\Iore  recently,  Burge,  Kennedy,  and  Neill^^  found 
that  thyroid  feeding-  increases  the  catalase  of  the  blood,  while 
decreasing  it  in  the  heart  and  probabh^  in  the  fat  and  skeletal 
muscles.  The  increase  in  blood  catalase  may  account,  accord- 
ing to  these  investig"ators,  for  the  increased  oxidation  in  thy- 


DISEASES    OF    THE    TFIYROID.  97 

roid-fed  animals.  Numerous  clinicians  and  experimenters 
have,  indeed,  noted  that  thyroid  preparations,  as  well  as  path- 
ological hyperthyroidia,  are  capaljle  of  causing  through  aug- 
mented oxidation  a  rise  in  temperature  of  several  degrees  F. 
Thiele  and  Nehring^^  found  that  thyroid  extract  increases  by 
over  20  per  cent,  the  oxygen  intake,  and  the  carbon  dioxide 
output  almost  as  much.  After  thyroidectomy,  on  the  other 
hand,  opposite  conditions  prevail. 

From  the  viewpoint  of  E.  C.  Kendall,^^  ^^e  alpha  iodin 
compound  isolated  by  him  in  crystalline  form  from  the  thy- 
roid acts  in  the  body  specifically  by  the  deamination  of  amino- 
acids.  The  resulting  products  are  then  either  burned  directly  into 
carbon  dioxid  and  water  or  used  for  the  formation  of  carbo- 
hydrates, fats,  etc.  The  greater  the  amount  of  iodin  in  the 
cell,  the  greater  the  destruction  of  amino-acids,  and  ultimately, 
unless  the  proteins,  themselves  constituted  of  amino-acids, 
are  replenished,  they  too  will  be  exhausted.  The  function  of 
the  thyroid,  according  to  this  view,  is  "to  furnish  a  catalyzer 
which  regulates  the  rate  of  deamination."  The  colloid  matter 
is  looked  upon  as  a  vehicle  for  carrying  the  iodin  catalyzer 
from  the  gland  to  the  tissue-cells  when  a  heightening  of  cell 
activity  is  required,  and  for  carrying  it  later  back  to  the  thy- 
roid when  the  need  for  it  subsides. 

Merging  into,  and  scarcely  less  important  than,  the  prop- 
erty of  regulating  metabolic  changes,  is  the  function  of  the 
thyroid  in  resisting  and  overcoming  intoxications  and  bacterial 
infections.  Granting  oxidation  and  increase  of  temperature  to 
be  important  factors,  in  a  general  way,  in  the  destruction  of 
toxic  wastes  or  foreign  materials  and  of  bacteria  and  their 
harmful  products,  the  thyroid,  which  wihen  strongly  active 
favors  both  these  conditions,  cannot  but  be  considered,  a  priori, 
a  major  influence  in  the  protection  of  the  organism. 

In  1903,  Sajous,  Sr.,^"*  emphasized  for  the  first  time  the 
power  of  the  thyroparathyroid  secretion  to  increase  the  germi- 
cidal and  antitoxic  properties  of  the  blood.  In  1907,  Fassjn^^ 
observed  experimentally  that  the  administration  of  thyroid 
products  materially  increases  the  amount  of  germicidal  and 
hemolytic  alexins  (complement)  in  the  blood.  Clinically,. 
Leopold-Levi  and  de  Rothschild^Q  observed  thyroid  treat- 
ment rapidly  to  exert  a  favorable  influence  in  autointoxications 


98  DISEASES    OF    THE    DUCTLESS    GLANDS. 

and  exogenous  infections,  including  er}^sipelas.  Thyroidec- 
tomized  animals  succumb  easily  to  infections,  and  their  blood 
serum  and  urine  are  abnormally  toxic  to  other  animals,  sug- 
gesting that  intermediate  wastes  or  other  poisonous  materials 
are  not  adequately  destroyed  under  these  circumstances. 
Reid  liunt^"  found  thyroid-fed  mice  markedly  resistant  to 
poisoning  by  acetonitrile ;  Jeandelize  and  Perrin^^  found  thy- 
roidectomized  rabbits  unusually  susceptible  to  poisoning  by 
sodium  arsenate ;  and  Lorand  observed  a  similar  deficiency 
in  relation  to  chloroform  narcosis. 

Bacteria  being  relatively  rich  in  phosphorus,  as  shown  in 
the  fact  that  their  ash  is  largely  phosphoric  acid,  they  are  all 
the  more  vulnerable,  from  the  viewpoint  of  Sajous,  Sr.,  to  the 
destructive  action  of  thyroiodase — the  designation  applied  iDy 
him  to  the  iodin-containing  product  of  the  thyroid  when  com- 
bined with  the  adrenoxidase  furnished  by  the  adrenals.  From 
this  standpoint,  moreover,  the  secretion  of  the  pancreas  is 
also  an  effective  factor  in  the  autoprotective  process ;  while 
the  pituitary  body,  connected  with  the  th3-roid  and  adrenals 
through  the  sympathetic,  from  his  viewpoint,  constitutes  a 
governing  center  which  co-ordinates  their  secretory  activities. 
Palmer,S9  extirpating  the  main  thyroid  body  in  pigs,  observed 
that  a  degree  of  hypothyroidism  insufificient  to  cause  marked 
changes  in  the  physical  appearance  of  the  animal  yet  sufificed 
to  lower  considerably  the  resistance  to  infection,  as  well  as  to 
impair  the  functions  of  reproduction. 

THYROID  INSUFFICIENCY   (HYPOTHYROIDIA). 

While  the  manifestations  of  thyroid  insufficiency  are  ob- 
served in  their  most  intense  form  in  true  myxedema,  the  latter 
in  its  fully  developed  condition  is  relatively  rare.  Far  more 
frequent  are  the  cases  of  incomplete  or  "fruste"  myxedema, 
which  complicates  pathogenically  many  of  the  diseases  met  in 
daily  practice,  and  to  which  the  term  hypothyroidia  (hypothy- 
roidism ;  chronic  benign  hypothyroidia — Hertoghe)  may  con- 
veniently be  applied. 

An  essential  fact  to  be  borne  in  mind  in  this  connection 
is  that  the  symptomatology  of  hypothyroidia  does  not,  as  a 
rule,  embody  the  cardinal  myxedemic  symptoms.     The  mani- 


DISEASES   OK   THE   TinROID. 


90 


festations  of  hypothyroidia  oftcncsti  encountered,  sing-Iy  or  m 
combination,  comprise  severe  occipital  and  interscapidar  pain, 
obesity  with  supraclavicular  pads  of  fat,  low  body  temperature,' 
loss  of  hair  and  teeth,  lassitude,  inveterate  constipation,  and 
mental  torpor.     In  children,  these  manifestations  may  be'  sup- 


Fig.  1.— Hypothyroidia.     Physical  development  under  thyroid 
treatment.     (Uopold-Lcvi  and  de  Rothschild.) 

plemented  by  slow  physical,  mental,  and  irregular  skeletal  de- 
velopment, enlargement  of  the  lymphatic  glands,  and  occasion- 
ally enuresis. 

Headache  or  backache  frequently  constitutes  the  chief 
complaint.  Somnolence  on  rising,  with  a  subjective  feeling  of 
improvement  as  the  day  wears  on ;  chilliness,  due  to  deficTent 
metaboHc  activity,  and  a  fondness  for  stimulants,  are  also 
suggestive.  Other  features  include  premature  ageing' and  gray- 


100  DISEASES    OF   THE   DUCTLESS   GLANDS. 

ness  of  the  hair;  a  tendency  to  occipital  alopecia,  characteris- 
tically in  the  lateral  portions  of  the  eyebrows;  dryness  of  the 
hair,  a  waxy  hue  of  the  facial  skin,  and  puffy  eyelids.  Dyspnea 
or  oppression  on  exertion,  palpitations,  a  tendency  to  cardiac 
dilatation,  anemia,  early  loosening  and  caries  of  the  teeth, 
bleeding  and  receding  gums,  persistent  congestion  of  the 
mucosse  of  the  upper  respiratory  tract,  passive  enlargement  of 
the  liver,  and  a  tendency  to  varicose  and  calculous  disturb- 
ances, oliguria,  and  flat-foot  are  not  infrequent  manifestations. 

In  the  female  sex,  amenorrhea,  metrorrhagia,  or  dysmenor- 
rhea may  be  noted,  and  the  uterus  is  often  found  in  retro- 
flexion. Pregnancy  and  lactation,  exciting  the  thyroid  to  in- 
creased activity,  ma}'  markedly  improve  the  condition  for  the 
time  being,  or  in  occasional  cases  permanently.  On  the  other 
hand,  lactation  may  at  times,  by  imposing  exhausting  activ- 
ity on  the  adrenals,  lead  temporarily  to  increased  pallor,  a 
tendency  to  edema,  and  intellectual  torpor.  In  males,  impo- 
tence, spermatorrhea,  and  prostatic  hypertrophy  may  be 
observed. 

Imperfect  circulation  in  the  special  sense  organs  may  lead 
to  hallucinations  of  sight  or  various  forms  of  tinnitus.  The 
mind,  even  in  the  milder  cases,  is  apt  to  be  slightly  obtuse,  and 
a  melancholic  tendency  is  frequent.  Occasionally  there  is 
maniacal  excitement,  probably  due  to  inadequate  destruction 
of  wastes  in  the  blood. 

The  origin  of  hypothyroidia, '  which  may  occur  at  any 
period  of  life,  is  sometimes  hereditary ;  the  chief  causes  in  such 
cases  being  syphilis,  alcoholism,  and  the  gouty  diathesis. 
Pregnancy  may  in  this  form  lead  to  permanent  improvement  by 
stimulating  the  functional  activity  of  the  organ  and  causing  it 
to  hypertrophy.  The  acquired  form  of  hypothyroidia  not  in- 
frequentlv  originates  in  some  acute  infectious  disease,  causing 
interstitial  and  parenchymatous  changes  in  the  thyroid  which 
lead  later  to  sclerosis  and  atrophy.  Excessive  repetition  of 
pregnancy  and  thyroid  traumatism  are  also  at  times  causes 
of  acquired  hypothyroidia.  In  the  aged  the  condition  is  to 
some  extent  physiological,  all  the  ductless  glands  tending 
toward  retrogression  in  this  period — a  condition  probably  in 
itself  essential  in  the  causation  of  senilitv. 


DISEASES    UE    TllE    TilVRUlD.  101 

TREATMENT. 

The  chief  remedy  is  manifestly  dried  thyroid  (Thyroidciim 
siccum,  U.  S.  P.),  relief  being-  contingent,  however,  upon  suit- 
able dosage.  The  residual  secreting  power  of  the  gland  vary- 
ing in  different  cases,  care  in  the  adjustment  of  the  dose  is 
a  necessity.  In  adults,  0.06  gram  (1  gr.)  of  the  dried  gland 
three  times  a  day  during  meals  is  usually  a  sufficient  initial 
amount.  Later  this  may  be  increased  gradually  to  0.12  gram 
(2  gr.)  three  times  daily.  More  than  this  is  seldom  required, 
and  in  some  cases  but  0.03  gram  (^  gr.),  or  even  less,  three 
times  a  day  is  sufficient.  Excessive  dosage  in  any  given  case 
is  likely  to  bring  on  headache,  pain  over  the  kidneys  and  in 
the  joints,  muscles,  and  liver,  anorexia,  a  rapid  pulse,  a  rise  in 
temperature,  a  tendency  tow^ard  fainting,  tremor,  and  an  in- 
crease of  any  pre-existing  dyspnea.  Where  there  is  marked 
anemia,  dried  suprarenals  0.12  gram  (2  gr.),  and  Blaud's  pill- 
mass,  0.06  gram  (1  gr.),  may  be  advantageously  combined 
with  each  dose  of  thyroid  substance.  Properly  to  relieve  con- 
stipation, high  injections  of  saline  solution  two  or  three  times 
a  week  may  be  required  at  first,  after  which  glycerin  sup- 
positories may  be  used.  For  purgation  by  mouth,  salines 
should  be  given  preference.  As  a  rule,  the  thyroid  medication 
will  have  to  be  continued  indefinitely,  possibly  in  reduced 
dosage. 

Hemorrhage  from  the  uterus  in  6  cases,  including  3  of  ex- 
cessive menstruation,  the  condition  being  ascribed  in  all  to 
thyroid  insufficiency,  was  successfully  treated  by  Salzman^^ 
by  dried  thyroids  in  the  dosage  of  1  to  3  5-grain  (0.3  Gm.) 
tablets  a  day. 

Among  men  in  active  military  service,  Blanc^^i  has  ob- 
served very  many  examples  of  thyroid  disturbance,  including 
some  of  insufficiency  of  this  gland.  As  Petzetakis''-  had  pre- 
viously pointed  out,  the  oculocardiac  reflex  is  enormously  in- 
tensified in  hypothyroidia,  the  sympathetic  being  left  without 
its  normal  stimulation  from  the  thyroid,  ascendancy  of  the 
autonomic  nervous  structures  and  vagotonia  resulting.  Blanc 
noticed  that  under  either  thyroid  or  parathyroid  medication, 
or  both,  the  balance  was  restored  and  the  abnormal  oculocar- 
diac reflex  disappeared. 


102  DISEASES    OF    THE    DUCTLESS    GLANDS. 

MYXEDEMA  (PROGRESSIVE  HYPOTHYROIDIA). 

This  condition  arises  as  a  result  of  marked  or  complete  hy- 
pothyroidia  coming-  on  at  any  period  of  life  after  puberty,  and, 
as  an  expression  of  the  maximum  loss  of  thyroid  function,  is 
characterized  by  general  deficiency  of  oxidation  and  catabol- 
ism,  causing  hypothermia,  infiltration  and  swelling  of  the 
cutaneous  tissues,  an  increase  in  body  weight,  dryness  of  the 
skin,  pronounced  asthenia,  and  mental  torpor. 

Among-  such  patients  the  almost  continuous  suffering  from 
cold,  except  in  hot  weather,  leads  to  the  use  of  an  abnormal 
amount  of  coA'ering.  The  temperature  is  always  below  nor- 
mal, and,  the  circulation  as  well  as  the  processes  of  oxygena- 
tion being-  impaired,  the  least  exposure  to  cold  induces  cya- 
nosis of  the  peripheral  tissues.  The  infiltrated  cutaneous  tis- 
sues are  elastic  and  firm,  but  do  not  pit  on  pressure,  as  in 
true  edema.  The  abdomen  becomes  pendulous,  the  hands 
thickened,  and  the  nails  brittle  and  thin,  sometimes  ridged  or 
atrophied. 

The  skin  in  myxedema  often  becomes  rough  and  scaly. 
Patches  of  pigmentation,  varying  from  yellowish-brown  to 
actual  bronzing,  and  suggesting  participation  of  the  adrenals 
in  the  functional  torpor,  are  sometimes  obsen^'ed.  The  hair 
loses  its  luster,  becomes  coarse  and  brittle,  and  finally  falls 
out.  The  facial  expression  is  mask-like,  owing  to  the  cutan- 
eous infiltration.  All  the  mucous  membranes  similarly  be- 
come pale  and  tumefied;  the  condition  of  the  teeth  and  gums 
goes  from  bad  to  worse ;  and  the  attending  stomatitis  and 
salivation  result  in  dribbling  from  the  comers  of  the  mouth. 
Enunciation  is  imperfect,  and  the  voice  coarse,  nasal,  and  low- 
pitched.  Constipation  alternates  with  diarrhea,  and  there  is 
a  profound  distaste  for  meat. 

The  mental  state  is  characterized  by  somnolence,  apathy, 
amnesia,  and  irritability.  Exhaustion  upon  slight  exertion  is 
the  rule.  Sensation  is  impaired,  and  the  finer  movements  im- 
perfectlv  performed.  Headache  and  pains  in  the  muscles  and 
joints  are  common.  The  special  senses  are  obtunded  or  per- 
verted ;  and  hemorrhages,  apparently  due  to  povert}^  of  the 
blood  in  fibrin  ferment,  are  common.  Urea  excretion  is 
diminished. 


Fig.  1.  Fig.  2. 

Thyroid  Treatment  in  Myxedema.     [Hertoghe.] 

Fig.  1.  True  myxedema. 

Fig.  2.  The  same  patient  after  thyroid  treatment. 

IBulletin  de  V Academic  Royale  de  Medecine  de  Belgique.'] 


i)isi':.\.si';s  oi'   'liii':  '|■|l^U()ll).  103 

In  contrast  with  simple  liypcjtliyroidia,  ni\xcdcnia  is,  in  a 
sense,  progressive,  death  eventually  taking-  i)lace  from  exhaus- 
tion or  intercurrent  infection.  As  a  rule  the  condition  lasts  six 
to  twenty  years ;  but  occasionally,  especially  in  young  adults, 
it  may  run  its  course  in  six  months.  An  acute  type  of  myx- 
edema, with  death  within  a  few  days,  has  also  been  met  with. 

Myxedema  occurs  about  six  times  as  frequently  in  women 
as  in  men.  The  main  causes  are  rapidly  repeated  child-bear- 
ing", the  menopause,  worry,  mental  shocks,  and  injuries,  espe- 
cially to  the  head.  Where  a  familial  influence  is  operative, 
tuberculosis,  neuroses,  syphilis  or  alcoholism  is  apt  to  be 
found  in  the  patient's  antecedents. 

A  distinct  reduction  in  the  size  of  the  thyroid  gland,  char- 
acteristically the  seat  of  atrophic  change,  occurs  in  the  vast 
majority  of  cases  of  myxedema.  At  times,  however,  the  gland 
is  actually  enlarged  at  first,  then  gradually  atrophies 
irregularly. 

TREATMENT. 

Remarkable  results  are  obtainable  in  this  condition  by  thy- 
roid feeding.  Six  centigrams  (1  gr.)  of  dried  thyroid  three 
times  a  day  is  sufficient  at  first,  but  this  may  later  be  grad- 
ually increased  to  2  grains.  Restoration  of  the  body  tempera- 
ture to  normal  is  a  useful  guide  as  to  the  amount  actually  re- 
quired. If  the  temperature  rises  above  normal,  the  dose  should 
be  reduced.  The  pulse-rate  should  also  be  watched,  an  in- 
crease of  15  beats  per  minute  indicating  a  reduced  dose:  Ex- 
ertion is  to  be  avoided  during  the  treatment,  especially  at  first, 
lest  syncope  suddenly  supervene.  To  maintain  the  improve- 
ment, the  remedy  obviously  must  be  continued  throughout 
life";'  unless  thyroid  grafting-  is  performed  and  turns  out  suc- 
cessfully. (See  Infantile  Myxedema,  Treatment.)  Where  the 
heart  is  considerably  dilated,  small  doses  of  dignitatis  or  of 
dried  pituitary  or  suprarenal  will  materially  hasten  recovery. 

INFANTILE  MYXEDEMA  (CRETINISM). 

Thyroid  insufficiency  occurs,  in  this  condition,  before  the 
body  growth  is  complete ;  there  are  added,  therefore,  to  the 
morbid  phenomena  of  myxedema  in  adults  other  signs  per- 
taining to  the  developmental  period.    The  disease  is  thus  char- 


104  DISEASES    OF    THE    DUCTLESS    GLANDS. 

acterized  by  stunted  growth,  the  cretinic  facies,  with  flattened 
nose  and  thickened  lips  and  tongue,  a  harsh  skin,  and  more 
or  less  pronounced  idiocy.  The  abdomen  projects  forward 
considerably,  not  infrequently  exhibiting  an  umbilical  hernia. 
The  legs  are  short  and  bowed,  and  the  hands  broad,  with  stiff 
and  pudgy  fingers.  As  in  the  myxedema  of  adults,  vanous 
manifestations  of  subnormal  oxidation  occur.  All  the  muscles 
being  relatively  atonic,  the  child  is  feeble,  wobbles  in  walking, 
and  may  even  be  unable  to  stand  or  hold  up  its  head.  Con- 
stipation is  the  rule,  interrupted  by  occasional  attacks  of  diar- 
rhea. The  genitals  are  usually  imperfectly  developed,  though 
occasionally,  on  the  contrary,  the  sexual  instincts  are  en- 
hanced. Menstruation  often  fails  to  appear,  or  may  be 
menorrhagic. 

From  the  mental  standpoint,  the  cases  have  been  divided 
by  the  brothers  AVenzel  into  three  groups :  the  cretins,  unable 
to  speak;  the  semicretins,  simple-minded,  but  able  to  speak  in 
an  imperfect  manner;  and  the  cretinoids,  possessing  some  in- 
telligence, but  presenting  ph3"sical  evidences  of  cretinism. 

The  cases  are  also  necessarily  divided  into  the  endemic  and 
sporadic  types,  the  former  constituting  frequently  a  family 
disease,  observed  in  groups  of  cases  in  special  localities,  and 
ascribed  to  some  chemical  substance  or  micro-organism  pecu- 
liar to  the  waters  used  in  those  districts.  In  a  certain  propor- 
tion of  cases,  it  is  believed,  endemic  cretinism  may  be  con- 
genital. In  a  considerable  number  of  the  endemic  cases,  a 
more  or  less  voluminous  goiter  exists. 

Sporadic  cretinism  is  met  with  in  localities  free  of  endemic, 
grouped  cases,  and  among  healthy  families.  The  condition 
is  ascribed  to  some  thyroid  lesion  caused  by  an  acute  febrile 
'disease  or  intoxication,  either  before  or  after  birth.  Among 
the  most  frequent  infectious  causes  are  typhoid  fever,  scar- 
latina, pneumonia,  and  pertussis. 

TREATMENT. 

Growth  arrested  by  cretinism  is  restored  with  surprising 
rapidit}^  by  thyroid  treatment,  the  child  developing  some- 
times by  over  an  inch  per  month,  until  the  stature  normal  at 
the  corresponding  age  has  been  attained.  As  regards  mental 
development  the  results,  while  remarkable,  may  not  be  com- 


Fig,  1. 


Fig.  2. 


Thyroid  Extract  in  Cretinism.     [/.  B.  AIcGcc] 

Fig.  1.  Cretinic  idiot  7   years   old   wlien   thyroid   treatment   was   begun. 

Had  ceased  to  develop  when  3  years  old. 
Fig.  2.  Changes  after  one  year's  treatment.     Growth,   6V2  inches. 

[Cleveland  Medical  Gazette.] 


DISEASES    OF    THE    THYROID.  105 

plete  unless  the  treatment  has  been  started  early.  Where  an 
interval  of  years  has  elapsed  between  the  onset  of  cretinism 
and  the  beginning  of  treatment,  the  intelligence  regained  does 
not,  as  a  rule,  attain  that  of  the  normal  child. 

As  in  adult  myxedema,  careful  adjustment  of  dosage  is 
necessar3^  Excessive  dosage  not  only  entails  danger  of  sudden 
heart-failure,  but  may  also  lead  to  softening  of  the  bones, 
owing-  to  an  unduly  rapid  growth — a  tendency  to  be  guarded 
against,  if  the  bones  begin  to  yield,  by  the  application  of  suit- 
able braces.  At  times  toxic  symptoms  may  develop  in  a  sud- 
den, unexpected  manner,  the  drug  being  in  a  sense  cumulative 
in  its  action.  Seemingly,  such  results  are  more  likely  to  be 
produced  when  the  glandular  preparation  used  is  old.  An  in- 
fant can,  as  a  rule,  be  given  0.03  gram  {jA  gr.)  of  dried  thyroid 
once  daily,  a  child  of  two  years,  twice  daily,  and  older  children, 
3  times  a  day,  or  0.06  gram  (1  gr.)  twice  daily.  As  recom- 
mended by  Morton,  the  child  should,  as  a  precautionary  meas- 
ure, be  kept  recumbent  after  the  last  dose,  given  late  in  the 
day.  When  the  normal  body  temperature  has  been  reached 
under  the  influence  of  the  treatment,  0.06  gram  (1  gr.)  of 
dried  thyroids  on  retiring  will,  as  a  rule,  be  sufficient  to  pre- 
vent recurrence.  Danger  signals  necessitating  a  reduction  in 
dosage  comprise  a  rapid  pulse,  dizziness,  pains  in  the  back  and 
extremities,  general  weakness  and  a  syncopal  tendency,  or, 
ultimately,  nausea  and  vomiting,  a  pronounced  rise  of  tem- 
perature, and  collapse.  In  cretins  who  have  reached  adult  age 
before  treatment  is  started,  improvement  is  but  slight,  or  may 
be  nil.  Again,  in  sporadic  cases  the  improvement  is  more 
marked  than  in  the  endemic,  irreparable  injury  having  often 
been  produced  in  the  latter  type  before  treatment,  while  in  the 
former  the  earliest,  most  important  stages  of  growth  may  have 
been  passed  before  the  onset  of  the  disease. 

To  antagonize  any  accompanying  tendency  to  softening  of 
the  bones,  the  administration  of  syrup  of  lactophosphate  of 
lime  in  teaspoonful  doses  may  prove  a  useful  adjuvant  to  thy- 
roid treatment.  Dried  thymus  gland  0.3  gram  (5  gr.)  thrice 
daily,  is  also  of  advantage. 

To  obviate  the  necessity  of  thyroid  medication  throughout 
life,  thyroid  grafting  has  been  rather  widely  experimented 
with,  though,  on  the  whole,  with  disappointing  results.     Ac- 


106  DISEASES    OF   THE   DUCTLESS   GLANDS. 

cording  to  Cristiani,^^  i\^q  grafts  must  be  of  normal  human 
thyroid  tissue,  and  be  introduced  only  in  very  vascular  sub- 
cutaneous tissue,  in  small  but  multiple  masses.  Charrin  and 
Cristiani'^"*  obtained,  however,  good  results  also  with  sheep's 
thyroid.  In  a  series  of  cases  the  latter  observer^^  noted  dis- 
tinct improvement  in  60  per  cent.,  remarkable  results  in  34 
per  cent.,  and  no  improvement  in  6  per  cent.  Kummer^*^  has 
reported  a  successful  autograft  of  normal  segments  of  the  thy- 
roid under  the  skin  over  the  right  acromion  in  a  woman  with  a 
large  goiter,  in  whom  both  lobes  of  the  goiter  had  been  almost 
completely  removed.  Charles  Goodman^"  concluded  from 
experimental  work  in  dogs  that  as  yet  no  means  were  avail- 
able for  prolonging  indefinitely  the  life  of  an  entire  organ 
transplanted  from  one  animal  to  another.  He  agrees  with 
Carrel,  Lexer,  and  others,  however,  that  autotransplantation 
is  practicable.  In  his  experiments  the  arterial  supply  of  the 
transplant  was  provided  for  by  suture  of  an  attached  segment 
of  carotid  into  the  carotid  of  the  host,  and  the  venous  supply 
by  end-to-end  suture  of  the  thyroid  vein  with  the  central  end 
of  the  external  jugular  of  the  opposite  side.  In  autotrans- 
plantation, the  author  thus  succeeded  in  two  consecutive  in- 
stances in  retaining  the  thyroid  gland  in  its  normal  state 
microscopically.  Among  the  homotransplantations  there  were 
a  few  instances  in  which  parathyroid  tissues  remained  normal 
while  the  thyroid  showed  evidences  of  hemolysis.  Kocher,^^ 
while  recognizing  that  thyroid  transplantation  acted  even 
more  eftectually  and  promptfy  than  thyroid  medication  in 
myxedematous  states,  concluded  that  a  single  transplantation 
w^as  insufficient,  and  asserted  that  a  possible  method  of  obtain- 
ing a  permanently  active  transplant  would  be  to  decrease  the 
immunity  of  the  recipient,  such  immunity  tending  to  hasten 
destruction  of  the  transplanted  tissue. 

MYXEDEMATOUS  INFANTILISM. 

In  this  condition  the  deficiency  of  thyroid  function  is 
manifested  particularly  in  a  persistence  of  the  physical  and 
mental  characteristics  of  childhood  rather  than  in  the  actual 
idiocy  and  dwarfism  of  the  cretin.  AAHiile  the  most  severe 
cases  are  virtually  instances  of  mild  cretinism,  and  do  exhibit 


DISEASES    OF   THE   TltYROlD.  107 

Sortie  of  the  physical  characteristics  of  this  disorder,  an  essen- 
tial feature  of  the  average  case  is  the  tendency  toward  reten- 
tion, both  as  to  ideas,  judgment,  and  emotions,  of  the 
intellect  of  much  younger  subjects.  Physically,  the  heart  is 
excitable,  varicose  disorders  and  hemorrhagic  tendencies  are 
frequent,  and  the  genitals  may  remain  of  rudimentary  size. 
In  the  mildest  forms  the  signs  of  myxedema  are  hardly  dis- 
cernible, and  physical  development  may  even  surpass  the 
average.  In  males,  however,  the  general  conformation  fre- 
quently resembles  that  of  the  female. 

TREATMENT. 

Thyroid  products  constitute  the  chief  therapeutic  resource, 
as  in  cretinism.  The  younger  the  patient,  the  more  likely  is 
improvement  to  occur.  After  puberty,  the  results,  from  the 
standpoint  of  the  mentality,  are  seldom  satisfactory. 

THYROIDITIS. 

Acute  hyperemia  or  actual  inflammation  of  the  thyroid 
gland  is  generally  a  result  of  some  infectious  disease.  In  the 
presence  of  mere  hyperemia,  slight  swelling  of  the  gland,  with 
some  tenderness  and  dysphagia,  are  alone  noticed.  In  acute 
thyroiditis,  however,  severe  local  as  well  as  general  manifesta- 
tions occur,  a  chill  marking  the  usually  sudden  onset,  which  is 
followed  by  considerable  svi  elling  of  the  gland,  marked 
dysphagia  and  radiating  pains,  dyspnea  from  tracheal  com- 
pression, and  possibly  paralysis  of  the  recurrent  laryngeal 
nerve  or  edema  of  the  glottis.  Fever  may  be  high  in  spite 
of  the  absence  of  suppuration,  and  the  tachycardia  typical  of 
thyroid  overactivity  has  also  been  observed,  independently  of 
fever.  In  a  few  days,  as  a  rule,  the  morbid  condition  subsides ; 
resolution  without  suppuration  occurs  in  40  per  cent,  of  the 
cases.  Where  suppuration  does  develop,  the  abscesses  are,  as 
a  rule,  multiple,  each,  however,  tending  to  break  through  the 
adjoining  soft  tissues,  thus  leading  to  confluence,  rupture  through 
the  skin,  or  purulent  infiltration  of  surrounding  structures,  at 
times  leading  to  dangerous  complications,  such  as  pneumonia 
and  pyemia.  The  abscesses  bleeding  easily,  severe  capillary 
hemorrhages  sometimes  constitute  a  complication. 


108  DISEASES    OF    THE    DUCTLESS    GLANDS. 

The  infections  leading  to  acute  thyroiditis  comprise  such 
disorders  as  diphtheria,  typhoid  fever,  scarlatina,  mumps,  ton- 
sillitis, erysipelas,  pneumonia,  measles,  pertussis,  rheumatic 
fever,  puerperal  fever,  etc.  A  toxic  thyroiditis  due,  e.g.,  to 
iodids.  is  also  recog"nized.  The  wealth  of  the  thyroid  tissue  in 
vascular  channels  is  such  that  even  in  the  absence  of  actual 
th3'roiditis,  a  high  blood-pressure,  such  as  that  of  fevers,  may 
lead  to  interstitial  hemorrhages.  Either  through  subsequent 
interstitial  sclerosis  or  because  of  degeneration  of  the  epi- 
thelium in  thyroiditis,  the  thyroid  functions  may  become  so 
impaired  as  to  lead  to  marked  evidences  of  hypothyroidia,  or 
even  typical  cretinism.  On  the  other  hand,  as  pointed  out  by 
Theisen,'^^  after  thyroiditis  complicating  acute  tonsillitis,  hy- 
perthyroidism may  develop. 

Chronic  thyroiditis  may  follow  the  acute  t}^pe,  resolution 
having  been  incomplete.  Oftener,  however,  it  accompanies 
such  chronic  disturbances  as  syphilis,  tuberculosis,  actinomy- 
cosis, and  echinococcus  disease.  The  resulting  ultimate  reduc- 
tion in  thyroid  a.ctivity  is  a  most  common  cause  of  hypo- 
thyroidia. 

A  parasitic  form  of  thyroiditis,  due  to  a  flagellate  organism 
(Schi::otrypaiiinn  cnt::;!),  is  frequently  encountered  in  the  State 
of  Alinas  Geraes,  Brazil. 

TREATMENT. 

In  infectious  diseases  the  thyroid  should  be  carefully 
watched,  and  where  local  pain,  tenderness,  or  swelling-  de- 
velops, cold  compresses  should  be  applied,  not  only  to  cause 
contraction  of  the  vessels  beneath,  but  to  reduce  the  local 
temperature,  and  thereby  also  the  activity  of  the  protective 
principles  concentrated  in  the  thyroid,  which,  in  thyroiditis, 
probably  exceed  the  limits  of  beneficial  action,  and  lead  to 
autolysis  of  the  gland  tissue.  Saline  solution,  by  mouth,  rec- 
tum, or  the  subcutaneous  route,  is  also  of  importance  in  these 
cases.  A  high  blood-pressure,  tending  to  perpetuate  thyroid 
congestion,  may  at  times  be  advantageously  lowered  with 
such  agents  as  chloral  hydrate  and  veratrum  viride.  Rest  is, 
as  in  other  local  inflammations,  an  important  measure,  and 
leeching  may  exert  a  useful  decongestive  effect  For  dyspnea 
of  alarming  degree,  tracheotomy  ma}^  be  required. 


DISEASES    OI<    THE    Tli\'R()IU.  109 

Suppuration  occurring  in  approximately  a  half  of  all  cases, 
the  frequent  advisability  of  surgical  intervention  must  be 
borne  in  mind.  The  presence  of  pus  being  difficult  of  demon- 
stration, exploratory  puncture  may  prove  of  assistance.  Ac- 
cording to  Kocher,!***^  if  incision  does  not  result  in  rapid  re- 
cover}', multiple  abscesses  should  be  suspected;  persistence 
of  a  sinus  points  to  extensive  necrosis,  and  the  affected  half 
of  the  gland  should  then  be  excised. 

In  chronic  thyroiditis  leading  to  hypothyroidia  thyroid 
treatment  should  be  instituted.  Removal  of  chronically  dis- 
eased thyroid  tissue  may  be  advisable,  particularly  where 
dyspnea  is  troublesome.  De  Massaryioi  has  reported  a  case 
of  chronic  syphilitic  thyroiditis,  w^ith  marked  impairment  of 
the  intellectual  powders,  in  w^hich  thyroid  medication  restored 
the  mental  condition,  and  mercury  (begun  only  six  months 
later)  reduced  the  thyroid  gland,  previously  large  and  soft, 
to  more  nearly  normal  dimensions. 

THYROID  OVERACTIVITY  (HYPERTHYROIDIA) 
AND  EXOPHTHALMIC  GOITER. 

Some  of  the  physiological  disturbances  aw^akened  by  ex- 
cessive thyroid  functioning,  in  particular  the  marked  heighten- 
ing of  general  metabolism  and  oxidation,  w^ere  referred  to  at 
the  beginning  of  this  section.  By  the  term  hyperthyroidia — 
or  larval,  "fruste"  exophthalmic  goiter — may  conveniently  be 
designated  those  instances  of  thyroid  overactivity  in  which 
certain  cardinal  symptoms  of  true  exophthalmic  goiter,  viz., 
exophthalmus  and  goiter,  are  lacking.  In  its  etiology,  path- 
ology, symptomatology,  and  medicinal  treatment,  however, 
hyperthyroidia  is  very  similar  to  exophthalmic  goiter — 
Graves's,  Basedow's,  or  Parry's  disease. 

That  exophthalmic  goiter  is  due  to  excessive  activitv  of  the 
th5^roid  can  no  longer  be  doubted.  The  clinical  and  thera- 
peutic aspects  of  the  condition  render  it  advantageous  to 
recognize  three  stages:  (1)  the  sthenic  or  ere  fine  stage,  in 
which  excessive  oxidation  and  abnormally  active  cellular 
metabolism  prevail ;  (2)  a  transitional  stage,  in  which  a  grad- 
ual restriction  of  the  thyroid  function,  due  to  sclerotic 
changes  and  atrophy  from  overwork,  is  initiated;  and  (3)  the 


no  DISEASES    OF    THE    DUCTLESS    GLANDS. 

asthenic  or  myxedematous  stage,  in  which  the  increasing  lack 
of  thyroid  function  is  definitely  manifest  in  symptoms  indica- 
tive of  hypothyroidia,  and  in  which  death  occurs. 

In  the  sthenic  stage  the  excessive  metabolism,  which,  ac- 
cording to  views  set  forth  by  the  writer  15  years  agc^*^-  is 
in  part  due  to  overactivity  of  the  adrenals  in  concomitance 
with  that  of  the  thyroid,  seems  to  involve  with  especial  sever- 


Fig.  2. — Graves's  disease  with  pronounced  thj-roid  enlargement 
and  exophthalmus.  (From  Da  Costa's  Physical  Diagnosis.  Copy- 
right, W.  B.  Saunders  Co.) 

ity  the  structures  rich  in  phosphorus,  including  the  nervous 
S3"stem,  Chittenden^''^  having  laid  stress  on  the  marked  in- 
crease in  phosphoric  acid  excretion  in  this  condition.  Mani- 
festations of  such  excessive  phosphoric  metabolism  are :  the 
characteristic  nen'ousness  and  tremor  of  exophthalmic  goiter, 
and  the  convulsive  movements  sometimes  noticed.  That  oxy- 
gen consumption  and  carbon  dioxid  elimination  are  often  aug- 
mented to  a  surprising  degree  has  been  definitely  established, 
and.  concomitantly,  there  is  frequently  an  increase  of  the 
body  temperature  to  100°  or  101°,  or  a  recurrent  actual  febrile 


DISEASES    OF    THE   THYROID. 


Ill 


State,  in  which  even  such  temperatures  as  107°  to  110°  have 
exceptionally  been  recorded.  According  to  DuBois,!'^'*  who 
studied  metal)oHsm  in  11  patients  with  a  respiration  calori- 
meter, heat  production  g'ives  the  best  indication  of  the  severity 
of  the  disease  in  a  given  subject.  Some  of  his  cases  sliowed 
an  increase  of  75  per  cent,  or  more  above  normal  in  heat  pro- 
duction ;  the  moderately  severe  and  most  of  the  mild  cases,  an 
increase  up  to  50  per  cent. 


Fig.  3. — Graves's  disease  without  exophthalmus.     (From  Da  Costa's 
Physical  Diagnosis.    Copyright,  W.  B.  Saunders  Co.) 


Other  well-known  manifestations  of  the  erethism  of  this 
stage  of  the  disease  are  the  tachycardia,  the  abnorjnal  irrita- 
bility of  the  alimentary  canal  (manifested,  e.g.,  in  g-astric  hy- 
peresthesia and  diarrhea),  and  the  general  vasodilation  and 
low  blood-pressure,  apparently  due,  at  least  in  part,  to  the 
special  excitation  of  the  depressor  nerve  noticed  experiment- 
ally as  an  effect  of  thyroid  products  by  Cyon  many  years  ago. 
Seemingly  dependent  on  this  general  tendency  to  vascular 
atonicity  are  the  flushing  of  the  skin,  epistaxis,  hemorrhagic 
areas  in  the  mucous  membranes,  edemas  in  the  eyelids  and 
lower  limbs,  exophthalmus,  etc. 


112  DISEASES    OF    THE    DL'CTLESS    GLAXDS. 

AMiile  some  cases  of  exophthalmic  goiter  are  spontaneously 
recovered  from,  and  others  soon  succumb  in  the  erethic  stage 
after  suddenly  entering  a  rapid  downward  course,  very  many 
come  eventually  into  a  phase  in  which  there  seems  to  be  con- 
siderable improvement.  The  skin  moisture,  the  sensations  of 
heat,  and  the  nervous  phenomena,  including  tachycardia,  the 
emaciation,  etc.,  tend  to  abate.  The  goiter  may  recede  some- 
what, and  exhibit  palpable  nodules,  indicative  of  localized 
sclerotic  changes  in  the  thyroid  parenchyma.  From  this  (the 
transitional  stage)  the  case  then  passes  into  the  third  phase, 
that  of  myxedema,  with  the  customary  manifestations  of 
which  are  coupled  certain  indications  of  exhaustion  of  the 
adrenals — in  particular,  pigmentations  of  the  skin.  To  the 
ordinary  signs  of  myxedema  are  added  greater  cardiac  weak- 
ness and  dilatation,  owing  probably  to  exhaustion  of  and  per- 
manent injur\^  to  the  myocardium  during  the  sthenic  stage. 
To  some  intercurrent  disease,  or  a  cachexia  terminating  in 
heart  failure,  the  case  ultimately  succumbs. 

Participation  of  the  thymus  in  the  pathogenesis  of  ex- 
ophthalmic goiter  has  been  emphasized  of  late.  In  about  82 
per  cent,  of  cases  examined  post-mortem,  in  whom  death  had 
been  due  to  intercurrent  disease,  a  persistent  thymus  has  been 
found,  while,  according  to  the  observations  of  Haberer,  in- 
jection of  thymus  gland  extract  is  capable  of  inducing  thyro- 
toxis.  Bircher  has  produced  typical  exophthalmic  goiter 
symptoms  by  implanting  fresh  hyperplastic  thymus  tissue  in- 
traperitoneally.  Where  the  goiter  is  small,  dyspnea  on  exer- 
tion, with  a  sensation  of  pressure  behind  the  manubrium,  or 
dysphagia,  with  the  "feeling"'  of  a  lump  in  the  same  situation, 
are  indications  of  thymic  involvement — a  condition  confirmed 
by  .r-ray  examination  and  the  finding  of  dullness  over  the 
thymic  area.  An  added  danger  where  the  thymus  is  involved 
is  that  sudden  death  may  occur  during  or  even  some  days  after 
an  operation  on  the  thyroid. 

"  In  the  etiology  of  exophthalmic  goiter,  two  factors  stand 
out  above  all  others,  viz.,  the  toxic  or  infectious  and  the  nen,"- 
ous.  The  former  group  includes  not  only  bacterial  toxins, 
but  also  autogenous  toxic  substances  absorbed  from  the  ali- 
mentary' canal  because  of  imperfect  digestion  of  nitrogenous 
foods.    Ether  anesthesia,  and  A-iolent.,  prolonged  physical  work 


*      DISEASES    OE    THE   THVROIU.  113 

have  also  occasionally  l^een  causative.  In  the  nervous  .i^roup 
belong  ang"er,  fright,  and  other  emotions,  traumatic  shock, 
blows  upon  the  head,  etc.  Such  causes  may  be  held  operative 
throug-h  disturbance  of  the  sympathetic,  w^hich  governs  the 
caliber  of  the  arterioles  of  the  thyroid.  As  Cannon^'^-'j  has 
shown,  the  thyroid,  like  .the  adrenals,  has  an  emergency  func- 
tion, serving  at  critical  times  to  accelerate  metabolism  to  an 
unusual  rate.  Like  the  adrenals,  furthermore,  the  thyroid  was 
found  by  Cannon  to  receive  impulses  through  the  sympathetic 
system.  The  pituitary  body  embodying,  according  to  the 
senior  writer,  a  governing  center  of  the  sympathetic  system, 
the  possibility  that  this  organ  might  be  the  primary  seat  of 
the  nervous  disturbance  in  these  cases  has  been  suggested. 
Apparently  in  many  instances  a  toxic  and  an  emotional  or  trau- 
matic factor  co-operate  in  the  etiology  of  exophthalmic  goiter. 
The  European  war  has  afforded  numerous  examples  of  the 
disease  arising-  either  through  trauma  to  the  head,  physical 
or  mental  overwork,  intoxication  from  poor  food  or  water, 
and  infections  such  as  dysentery  and  typhoid  or  paratyphoid 
fever.  Pietrowicz^'^^  rightly  laid  stress  on  infectious  condi- 
tions in  the  mouth,  teeth,  tongue,  nose,  tonsils,  pharypx,  and 
larynx  as  a  factor  in  the  disease. 

TREATMENT. 

An  important  feature  of  the  medical  treatment  is  to  pro- 
mote contraction  of  dilated  vessels,  especially  those  of  the 
thyroid  gland  itself,  and  those  of  the  postorbital  region.  Prob- 
ably to  such  an  action  are  to  be  attributed  the  good  results  ob- 
tained by  Huchard,  Paulesco,  and  others  from  the  administra- 
tion of  erg'ot  in  combination  with  quinin.  An  effectual  mode 
of  applying  this  treatment  is  that  recommended  by  Forch- 
heimer,  who  gave  in  a  capsule  0.06  gram  (1  ,gr.)  of  ergotin 
(watery  extract  of  ergot)  and- 0.3  gram  (5  gr.)  of  neutral  hy- 
drobromid  of  quinin  after  each  meal.  Where  no  signs  of  cin- 
chonism  develop,  a  fourth  capsule  may  be  taken  at  bedtime. 
To  obviate  unpleasant  effects,  as  well  as  to  reduce  the  central 
erethism,  1.3  gram  (20  gr.)  of  sodium  bromid  at  bedtime  may 
also  be  given  with  advantage,  together  with  0.6  gram  (10  gr.) 
of  chloral  hydrate  where  sleeplessness  is  further  complained  of. 
In  some  highly  nervous  women  whom  quinin  disturbs,  acet- 


114  DISEASES    OF    THE    DUCTLESS    GLANOS. 

phenetidin  in  0.3-gram  (5-gr.)  doses,  gradually  increased  to 
0.6  gram  (10  gr.)  three  times  a  day,  may  be  used  with  benefit 
to  supplement  the  bromid  and  chloral. 

Probably  acting-  in  a  similar  manner  is  pituitary  extract 
which,  according  to  Hallion  and  Carrion,iOT  exerts  an  intense 
vasoconstrictor  action  on  the  thyroid.  Pal^^s  hg^g  reported  a 
case  improved  by  pituitary  injections,  while  Richter^OQ  has 
had  good  results  in  several  cases  from  dail}^  administration  of 
3  to  5  5-grain  (0.3  Gm.)  tablets  of  extract  of  anterior  lobe  of 
the  pituitary. 

According  to  Kocher  and  others,  sodium  phosphate  is  of 
considerable  value  in  exophthalmic  goiter.  Calcium  salts, 
sodium  sulphate  or  glycerophosphate,  and  lecithin  in  an  alco- 
holic solution  have  also  been  recommended. 

Rest  is  a  measure  of  the  utmost  importance  in  all  but  very 
mild  cases.  A.  J.  Ochsner's  rules^o  as  to  rest  and  diet  in 
these  cases  after  operation  are  likewise  applicable  with  advan- 
tage in  the  purely  medical  treatment  of  the  disease.  All  ex- 
citement or  irritation  is  to  be  avoided,  and  the  patient  should 
get  plenty  of  rest,  going  to  bed  early  and  taking  a  nap  after 
lunch.  Nothing  irritating  to  the  nervous  system  should  be 
eaten  or  drunk.  Tobacco  should  be  avoided,  and  very  little 
meat  used.  Meat  broths  should  be  eschewed.  Milk  and  foods 
prepared  with  milk  are  to  be  freely  taken ;  likewise  cooked 
fruits  and  vegetables,  or  very  ripe,  raw  fruits.  Eggs,  bread, 
butter,  toast,  rice,  and  cereals  are  all  permitted.  Good  drink- 
ing water  should  be  used  freely,  if  good  water  is  not  available, 
the  water  to  be  drunk  should  be  boiled  for  twenty  minutes,  or 
distilled  water  used. 

An  essential  measure  is  a  careful  search  for  any  underlying 
infectious  or  toxic  factor,  and  if  such  be  found,  its  eradication. 
Tonsillectomy  is  often  indicated.  AMiere  there  is  a  clear  his- 
tory of  acute  rheumatism,  sodium  salicylate  in  0.6-gram 
(10-gr.)  doses  three  times  a  day  will  often  satisfactorily  coun- 
teract the  hyperthyroidia.  Pyorrhea  alveolaris  appears  to  be 
a  very  frequent  cause.  For  many  toxic  underlying  states, 
saline  enteroclysis  at  108°  F.,  after  a  cleansing  enema,  is  an 
eliminatory  measure  of  considerable  value. 

In  cases  due  to  pregnane}^,  the  menopause,  or  ovarian 
underdevelopment,  in  which  the  disorder  seems  to  represent  an 


DisicAsiis  oi'  Till':  'rini^oiD.  115 

ineliectuul  attempt  of  the  organ  to  neutralize  accumulated 
wastes  in  the  blood,  dried  thyroids,  0.06  gram  (1  gr.)  thrice 
daily,  seem  not  infrequently  to  be  productive  of  good — thoug-h 
contraindicated  elsewhere — by  compensating-  for  the  insuffi- 
cient functional  capacity  of  the  thyroid.  Thymus  g-land  was 
accidentall}^  found  by  Owen  to  be  serviceable  in  exophthalmic 
goiter,  provided  the  case  is  not  one  with  concomitant  thymic 
enlargement.  The  dosage  is  1  to  3  0.3-gram  (5-gr.)  tablets 
three  times  a  day  during  meals.  S.  Solis-Cohenm  has  recom- 
mended thymus  in  conjunction  with  pituitrin,  the  latter  in  in- 
tramuscular injections. 

Such  preparations  as  Mobius's  antithyroidin,  Ballet  and 
Enriquez's  dog'  serum,  Rogers  and  Beebe's  serum,  and  thy- 
roidectin  have  not  yielded  convincing  results  in  our  hands. 

Where  measures  such  as  those  already  described  fail,  much 
may  be  done  by  the  injection  of  boiling  water  into  the  thyroid, 
as  suggested  by  M.  F.  Porter. ^^  Thg  larg-e,  gTaduated  glass 
syringe  used  in  this  procedure  is  boiled  in  the  water  used  for 
the  injection.  The  skin,  after  being*  cleansed,  is  anesthetized 
by  Schleich's  method.  By  the  use  of  a  long-  needle  both  the 
right  and  left  lobes  and  the  isthmus  may  be  injected  through 
1  skin  puncture,  made  in  the  median  line.  The  amount  of 
water  injected  by  Porter  rang'ed  from  2.5  to  15  mils  (40  to 
230  m.).  The  measure  causes  an  immediate  destruction  of  thy- 
roid tissue  and  colloid,  and,  after  a  short  period  of  irritative 
reaction,  benefit  is  rapidly  noticed.  At  least  one  death  having 
followed  the  procedure — albeit  in  a  most  desperate  case — other 
similarly  acting  but  safer  methods  have  been  sought,  and  one 
has  apparently  been  found  in  the  use  of  injections  of  a  steril- 
ized 30  to  50  per  cent,  solution  of  quinin  and  urea  hydrochlorid, 
which,  while  seemingly  devoid  of  danger,  causes  effectual 
necrosis  of  thyroid  tissue  and  subsequent  fibrosis,  thus  cutting 
down  as  much  as  may  be  desired  the  secreting  tissue.  Series 
of  bi-weekly  injections  of  such  a  solution  will  often  produce 
what  seems  to  be  a  permanent  cure,  even  in  very  pronounced 
cases.  L.  F.  Watsoni^'^  has,  among  others,  had  good  results 
from  this  method  of  treatment,  and  our  own  correspond  with 
his. 

Rontgen  ray  treatment  of  exophthalmic  goiter  may  now  be 
availed  of  without  risk  of  burns  since  the  introduction  of  pre- 


116  DISEASES    OF    THE    DUCTLESS    GLANDS. 

cise  methods  of  measuring  the  dose  of  rays  administered.  Ac- 
cording to  C.  A.  Simpson,!!^  .f-ray  treatment  is  always  the 
procedure  of  choice  where  thymus  enlargement  is  suspected, 
as  it  will  quickly  and  painlessly  atrophy  the  thymus  gland. 
Fischer,!!--*  treating  94  cases  with  the  rays,  obtained  positive 
benefit  in  77  to  80  per  cent.,  no  improvement  occurring  in  the 
remainder.  In  15  cases  all  objective  and  subjective  signs  and 
symptoms  of  the  disease  subsided  completely  under  the  treat- 
ment. Pfahler  and  Zulick^i^  believe  that  by  routine  trial  of 
.r-ray  treatment  many  thyroid  operations  can  be  avoided,  but 
warn  that  the  treatment  must  not  be  too  prolonged,  or  hypo- 
thyroidia  may  be  induced.  Increased  weig'ht  and  a  decrease 
in  the  pulse-rate  are  the  first  signs  of  improvement,  and 
nearly  always  occur.  The  goiter  and  exophthalmos  are  the 
last  manifestations  to  improve,  and  in  many  cases  they  remain 
uninfluenced. 

In  the  transitional  stage  of  exophthalmic  goiter  signs  of 
myxedema  are  apt  to  be  present,  and  treatment  for  their  cor- 
rection may  have  to  be  instituted.  In  the  myxedematous  stage 
the  necessity  for  thyroid  treatment  will  be  obvious,  together 
with  digitalis  or  strophanthus  to  antagonize  the  marked  tend- 
ency to  cardiac  failure. 

Surgical  Treatment.  The  reports  of  careful  clinicians  seem 
to  indicate  that  a  cure  of  the  condition  can  be  encompassed  by 
non-operative  methods  in  from  80  to  90  per  cent,  of  cases. 
From,  the  standpoint  of  the  average  surgeon,  on  the  other 
hand,  exophthalmic  goiter  is  largely  a  surgical  disease,  in 
which  prolonged  attempts  at  curative  medical  treatment  con- 
stitute a  mere  waste  of  time.  Doubtless,  an  intermediate 
ground  is  more  in  keeping  with  the  true  necessities  of  the 
condition  then  either  extreme,  but  an  important  fact  to  be 
realized  is  that  most,  if  not  all,  cases  are  secondary  to  some 
underlying  toxic,  infectious,  or  nervous  condition,  removal  of 
which,  whether  b}'  medical  or  simple  surgical  means  (ton- 
sillectomy, for  example),  will,  if  accomplished  sufficiently  early, 
remove  all  need  for  the  more  serious  interv'entions  on  the  thy- 
roid gland  itself. 

The  risk,  slight  but  not  negligible,  attending  operations  on 
the  thyroid  is  illustrated  in  the  mortality  percentages  men- 
tioned by  Berkman,!!"  referring  to  the  experience  at  the  Mayo 


Diseases  of  the  thyroid.  117 

Clinic  from  1910  to  1915.  In  these  successive  years,  respect- 
ively, the  operative  mortality  was  4.8,  3.18,  2.6,  3,  2.89,  and 
2.63  per  cent.,  the  cases  in  question  being'  all  instances  of  un- 
mistaka])le  Ityperthyroidism.  As  regards  the  ultimate  results 
from  operative  work,  Judd  and  Pembertonii'^  have  published 
a  statistical  study  of  cases  operated  upon  at  the  same  clinic 
in  1909,  and  traced  subsequently.  Of  121  cases,  55,  or  45  per 
cent.,  were  cured,  while  22,  or  18.1  per  cent,  still  had  some 
traces  of  the  disease.  In  5  of  the  cases  there  was  but  slight 
improvement,  and  in  8,  no  benefit.  The  average  period  re- 
quired to  efifect  a  cure  was  no  less  than  17.9  months. 

On  the  whole,  while  admitting  that  in  a  certain  percentage 
of  cases,  late  in  coming  under  treatment,  indications  may  exist 
for  surgical  treatment  as  soon  as  suitable  preparatory  meas- 
ures can  be  completed,  our  own  conviction  has  steadily  been 
increasing-  that  all  but  a  very  small  proportion,  probably  5  per 
cent.,  are  curable  without  surgical  measures.  The  field  for 
the  latter,  under  these  conditions,  is  largely  limited  to  cases  in 
which,  after  prolonged,  careful  modern  medical  treatment,  it 
is  evident  that  the  amount  of  secretion  cannot  be  sufficiently 
cut  down  in  any  way  other  than  actual  removal  of  the  gland. 
Even  this  contingency  seems  somewhat  remote,  presupposing 
that  all  non-operative  measures  be  unrelentingly  applied. 

With  such  destructive  procedures  as  boiling  water  and 
quinin  and  urea  injections  available,  not  to  speak  of  the  .^--rays, 
there  appears  little  reason  why,  if  such  measures  be  repeated 
until  widespread  destruction  of  gland-tissue  has  been  pro- 
duced, the  excessive  thyroid  function  causing  the  disease 
should  not  be  mastered  without  surgical  intervention. 

At  the  Mayo  Clinic  it  has  been  customary,  in  dealing  with 
these  cases,,  first  to  ligate  the  left  supermr  thyroid  vessels 
under  local  anesthesia.  If  no  reaction  follows,  it  is  considered 
safe,  after  a  week,  to  remove  the  right  lobe  of  the  gland,  or 
more,  if  indicated.  In  the  event,  however,  of  a  considerable 
reaction,  marked  by  exaggeration  of  the  tachycardia,  vomit- 
ing, diarrhea,  and  restlessness,  ligation  of  the  rig'ht  superior 
thyroid  vesels  is  also  performed,  after  subsidence  of  the  re- 
action. After  such  a  second  ligation,  it  is  considered  advisable 
to  wait  about  three  months  before  thyroidectomy,  the  case 
being  usually  changed  in  this  time  from   a  questionable  or 


118  DISEASES    OF   THE   DUCTLESS    GLANDS. 

serious  surgical  risk  to  a  good  one.  In  some  cases,  further- 
more, a  complete  cure  may  follow  the  two  ligations,  render- 
ing the  thyroidectomy  unnecessary.  Where  a  partial  thyroid- 
ectomy fails  to  cure,  resection  of  the  remaining  part  of  the 
gland,  it  is  asserted,  will  often  be  productive  of  much  good, 
the  cure  being  not  infrequently  rendered  complete  thereby. 
The  risk  of  provoking  myxedematous  symptoms  through  ex- 
cessive removal  of  thyroid  tissue  is,  of  course,  always  to  be 
borne  in  mind.  Sometimes,  on  the  other  hand,  S3miptoms  of 
hyperthyroidism  return  after  a  period  of  health,  through  trans- 
formation of  residual  tissue  into  a  goiter. 

Preliminary  preparation  for  an  operation  on  the  thyroid, 
even  an  arterial  ligation,  in  the  serious  cases,  is  an  important 
factor  in  helping  the  patient  safely  to  withstand  the  surgical 
procedure.  Such  preparation  includes,  in  particular,  absolute 
rest,  heart  tonics,  diuretics,  and  sometimes  the  .v-rays.  The 
latter  have  proven  serviceable  in  helping  patients  througii 
acute  attacks,  previous  to  operation.  Where  such  acute  symp- 
toms are  present,  thyroidectomy  must  be  postponed  until  they 
pass  off.  Irregularity  and  varying  tension  of  the  pulse,  diar- 
rhea, edema  of  the  hands  and  feet,  sleeplessness,  and  parox- 
,  ysms  of  gastric  pain  are  all  conditions  rendering  postpone- 
ment of  operation  advisable. 

Removal  of  the  thymus  at  operation  has  been  advised  by 
some,  owing  to  the  frequent  causal  relationship  of  this  organ 
to  the  disease.  In  Haberer's  experience,  a  combined  partial 
operation  on  both  thyroid  and  thymus,  in  the  cases  with  per- 
sistence of  the  latter  organ,  has  given  results  superior  to  those 
attending  thyroidectomy  alone.  In  the  x-rays,  however,  we 
have  a  procedure  which  will  effectually  reduce  the  thymus  in 
these  cases  before  the  thyroidectomy  is  undertaken,  thus  re- 
moving the  occasion  for  dealing  surgically  with  the  thymus, 
and  also  lessening  the  risk  from  the  thyroid  operation. 

GOITER. 

This  protean  condition,  the  essential  expression  of  which  is 
an  enlargement  of  the  thyroid  gland,  and  which  has  also  been 
termed  struma  or  bronchocele,  differs  from  exophthalmic 
goiter,  in  general,  in  the  absence  of  systemic  evidences  of  thy- 


Diseases  of  the  thyroid.  119 

roid  intoxication.  It  may,  however,  be  a  precursor  of  the 
exophthalmic  disease. 

Modern  research  has  plainly  demonstrated  that  goiter  can 
be  produced  by  a  number  of  different  toxic  agents,  inorganic 
or  organic.  In  many  goiter  districts  the  drinking  water  has 
been  shown  to  be  responsible.  Residuum  of  filtered  water 
from  cjprtain  fountains  in  Switzerland  was  found,  when  added 
to  harmless  water,  to  convey  to  it  goiter-producing  properties. 
Again,  limestone  districts  show  a  large  proportion  of  goitrous 
inhabitants.  According  to  Kocher,  "goiter  water  differs  from 
goiter-free  water  in  containing  many  more  micro-organisms." 
McCarrison  and  others  have  recently  afforded  strong  prac- 
tical support  to  the  bacteriogenic  view  of  goiter.  Animals 
allowed  by  McCarrison  to  drink  only  water  contaminated  with 
feces  very  readily  developed  goiter,  and  soil  deposits  on  the 
sides  and  bottom  of  water  channels,  tanks,  wells,  etc.,  were 
found  by  him  capable  of  contaminating  the  contained  water. 
The  participation  of  calcium  in  the  etiology  is  explained  on  the 
ground  that  it  affords,  in  the  soil,  a  favorable  medium  for  the 
pathogenic  micro-organism  responsible. 

Bacterial  infection  from  the  tonsils  can  undoubtedly  also 
provoke  goiter ;  likewise  infection  from  the  teeth  and  gums,  the 
nasopharynx,  and  many  other  situations. 

That  intoxication  by  intermediate  protein  waste  products 
may  provoke  goiter  is  indicated  by  many  clinical  and  some 
experimental  observations. 

Throughout,  the  effects  of  infections  or  other  toxic  ma- 
terials on  the  gland  are  most  easily  understood  when  the  view 
of  the  senior  writer  that  the  thyroid  and  parathyroids  are 
intimately  related  to  the  defense  of  the  body  against  poisons, 
exogenous  as  well  as  endogenous,  is  borne  in  mind.  The  organ 
becomes  enlarged  because  it  is  the  seat  of  an  excessive  defen- 
sive reaction  against  noxa  circulating  in  the  system. 

Five  distinct  types  of  goiter  may  conveniently  be  recog- 
nized :  (1)  simple  hypothyroid  non-toxic  goiter  (simple  or  par- 
enchymatous goiter),  in  which  the  increased  functional  de- 
mand has  provoked  congestion,  hyperplasia,  and  enlargement 
of  the  thyroid.  (2)  hyperthyroid  or  toxic  goiter,  in  which  ex- 
cessive secretory  activity  resulting  from  the  hyperplasia  has 
provoked   the   characteristic   symptoms   of  hyperthyroidia  or 


120  DISEASES    OF    THE    DUCTLESS    GLANDS. 

even  Graves's  disease,  though  in  most  cases  without  ex- 
ophthalmos; (3)  hypothyroid  degenerative  goiter^  comprising" 
the  colloid,  cystic,  and  fibrous  types,  etc.,  in  ^v"hich  the  changes 
noted  occur  probably  as  complications  of  the  hypothyroid 
non-toxic  goiter;  (4)  malignant  goiter;  smd  (5)  congenital  goiter 
or  goiter  of  the  nezcborn,  usualty  corresponding  pathologically 
with  the  congestive  or  hyperplastic  t\'pe  of  adults,  and  occur- 
ring frequentlv  in  the  offspring  of  goitrous  parents,  and  as  a 
result  of  pressure  during  birth. 

Simple  Hypothyroid  Non-toxic  Goiter.  The  enlargement 
of  the  thyroid  in  this  type  of  goiter  is  the  expression  of  an 
efifort  on  the  part  of  a  gland  weakened  through  hereditary  in- 
fluence or  previous  local  lesions  to  measure  up,  in  times  of 
stress,  to  the  functional  output  required  of  it.  Such  a  goiter 
rarelv  shows  a  true  hyperplasia  of  the  secreting  epithelium, 
the  chief  changes  being  a  pronounced  hyperemia  and  an  in- 
crease of  the  normal  cellular  elements. 

The  goiter  tends  to  persist,  unless  the  source  of  the  func- 
tional stress  on  it  can  be  found  and  removed,  and  tends  to 
undergo  colloid,  cystic,  or  other  changes.  It  tends,  moreover, 
toward  the  production  of  cretinism  or  myxedema,  and  in  many 
instances,  careful  obserA'ation  will  reveal  some  symptom  or 
other  of  hypothvroidism.  e.g.,  bradycardia,  hyperidrosis  of  the 
extremities,  slight  hypothermia  and  a  tendency  to  cold  feet 
and  hands,  and  a  reduction  in  urea  excretion.  Rheumatoid 
pains,  often  about  the  nucha  or  between  the  shoulders,  and 
especially  marked  when  the  patient  is  in  bed,  are  frequently 
observed.  At  first  the  gland  enlargement  ma}'  be  noticed  only 
upon  palpation  or  by  inspection  during  swallowing,  coughing, 
or  deep  breathing.  As  the  gland  enlarges  further,  the  trachea 
begins  to  be  compressed  or  distorted,  especially  when  one  side 
of  the  thyroid  is  much  larger  than  the  other,  causing  dyspnea. 
Headache  and  dizziness  from  pressure  upon  neck-vessels  may 
also  occur. 

An  .r-ray  examination  is  indicated  to  ascertain  whether  an 
intrathoracic  goiter  or  an  enlarged  thymus  coexists. 

Treatment.  Goiters  occurring  in  young  subjects  or  preg- 
nant women  occasionallv  recede  spontaneouslv  when  the 
causative  factor  has  ceased  to  operate,  but  as  a  rule  the  en- 
largement   tends    to    persist    and    become    gradually    more 


DISEASES    ()]'"    THE    THYROID.  121 

marked,  if  left  untreated.  In  endemic  goiter,  a  change  of 
drinking  and  cooking  water  is  often  an  important  measure  in 
the  treatment.  A  meat-free  diet,  or  at  least  the  omission  of 
red  meats  from  the  food,  is  helpful  in  most  cases.  Often  en- 
terogenous autointoxication  is  an  important  factor,  and 
wherever  intestinal  actiori  is  sluggish,  saline  aperients  should 
be  employed,  especially  sodium  phosphate,  the  latter  in  8- 
gram  (2  dr.)  daily  doses.  Certain  Swiss  observers,  mindful  of 
the  possible  water-borne  origin,  have  administered  intestinal 
antiseptics  such  as  phenyl  salicylate  and  betanaphthol,  with 
notably  beneficial  results.  Creosote  carbonate,  thymol,  and 
zinc  phenolsulphonate  have  also  been  used  for  bowel  anti- 
sepsis. McCarrison,!!^  attributing  endemic  goiter  in  India  to 
the  combined  action  of  an  ameba  and  of  bacteria  in  the  intes- 
tine— the  thyroid  being  unable  to  overcome  the  combined  toxic 
effects  without  undergoing  enlargement — administered  a 
mixed  bacterial  vaccine  in  33  cases  of  parenchymatous  goiter, 
with  excellent  results,  one  of  the  two  sources  of  burden  placed 
on  the  thyroid — the  bacterial  toxins — being  thus  eliminated. 
Langmead,i-0  in  8  cases  of  parenchymatous  goiter,  gave  vac- 
cines of  coliform  bacilli  obtained  from  the  patient's  own  bowel, 
this  causing  the  goiter  to  disappear  in  one  case,  and  reducing 
it  in  the  others. 

As  in  exophthalmic  goiter,  nearby  or  remote  foci  of  infec- 
tion which  might  be  factors  in  the  thyroid  enlargement  should 
be  diligently  sought  and  removed.  Catarrhal  disorders  of  the 
nasal  cavities,  ears,  tonsils,  lingual  tonsil,  etc.,  are  frequent 
causes  requiring  correction  either  by  antiseptic  measures, 
cauterization,  or  excision.  In  the  young,  adenoids  may  be  a 
cause  of  goiter.  Ulcerative  pelvic  conditions  at  times  require 
attention. 

Direct  relief  for  the  overworked  thyroid  gland  itself  is  pos- 
sible, this  group  of  cases  tending  toward  the  hypothyroid  type,  by 
the  administration  of  iodin  or  iodids,  avoiding,  however,  cases 
with  pressure-symptoms  or  rapid  growth  of  the  goiter. 
Sodium  iodid,  for  example,  may  be  given  in  0.3-gram  (5-gr.) 
doses  three  times  a  day,  gradually  increased,  if  well  borne,  to 
0.6  gram  (lO.gr.).  The  drug-  should  be  given  immediately 
after  meals  in  a  small  tumblerful  of  water.  Some  cases  respond 
better  to  Lug-ol's  solution  in  3-  to  5-  drop  doses.     In  general, 


122  DISEASES    OF    THE   DUCTLESS    GLANDS. 

iodin  is  safer  than  thyroid  substance  in  these  cases.  Further 
to  promote  the  action  of  the  iodin,  a  5  to  10  per  cent,  ointment 
of  iodopetrog"en  (N.  F.)  may  be  rubbed  into  the  gland  daily, 
using  a  piece  the  size  of  a  small  hazelnut,  until  skin  irritation 
begins  to  appear.  The  inunction  may  with  advantage  be  pre- 
ceded by  a  ten-minute  downward  and  outward  massage  of  the 
thyroid,  the  rubbing  movements  being  synchronous  with  deep 
respirations.  This  procedure  tends  reflexly  to  cause  contrac- 
tion of  the  vascular  channels  in  the  thyroid. 

A  rapid  pulse  does  not  necessarily  preclude  the  iodin  treat- 
ment, unless  accompanied  by  other  symptoms  of  larval  ex- 
ophthalmic goiter.  Where  distinct  cardiac  adynamia  is  de- 
tected, especially  when  manifest  in  dilatation  of  the  right 
ventricle,  digitalin,  0.006  gram  (%o  g"-""-)  twice  daily  will  assist, 
not  only  by  improving  circulation  in  the  body  at  large,  but 
likewise,  in  doing  so,  by  relieving  -congestion  of  the  thyroid. 

As  an  adjuvant  to  internal  treatment,  electricity  is  appar- 
ently sometimes  of  value,  presumably  by  promoting  contrac- 
tion of  vessels.  The  galvanic  current  to  the  amount  of  10 
or  more  milliamperes  may  thus  be  used  on  alternate  days,  the 
electrodes  being  placed  on  either  side  of  the  goiter.  Hasle- 
bacheri2i  has  had  good  results  in  goiter  from  vibratory  mas- 
sage, and  has  also  used  the  quartz  lamp  in  20  cases.  Under 
such  treatment,  he  reports,  the  symptoms  of  stenosis  soon  sub- 
sided, and  after  2  or  3  exposures  the  gland  became  softer. 

Surgical  trea-tment  will  be  referred  to  below  under  Hypo- 
thyroid Degenerative  Goiter. 

Hyperthyroid  or  Toxic  Goiter.  This  group  comprises 
those  cases  termed  .by  Plummer  "toxic  non-hyperplastic 
goiter,"  in  which,  although  some  symptoms  of  hyperthyroidia 
are  present,  the  typical  hyperplastic  glandular  changes  of 
Graves's  disease  do  not  exist.  Clinically,  most  if  not  all  of 
these  cases  strongly  resemble  instances  of  larval  exophthalmic 
goiter.  Such  hyperthyroidia  develops,  according  to  Brenizer, 
in  20  to  25  per  cent,  of  all  cases  of  simple  goiter,  most  fre- 
quently in  instances  of  diffuse  or  encapsulated  adenoma  of 
several  years'  standing. 

Treatment.  Fowler's  solution,  0.12  to  0.2  mils  (2  to  3  m.) 
three  times  daily  in  a  half-glassful  of  water,  appears  to  be  of 
value  when  a  goiter  tends  to  assume  the  Graves  type.     Bro- 


DlSEy\SES    (JE    THE   TllVROJD.  123 

mids  and  cold  compresses  over  the  gland  are  also  likely  to  be 
serviceable.  Where,  however,  symptoms  such  as  tremor  and 
tachycardia  persist  in  spite  of  such  treatment,  the  treatment 
for  exophthalmc  goiter  (q.v.)  should  be  resorted  to.  Among 
other  measures,  injections  of  quinin  and  urea  hydrochlorid 
have  proven  highly  effectual  in  the  hands  of  L.  F.  Watsoni22 
in  overcoming-  hyperthyroid  symptoms,  though  not  in  remov- 
ing the  gland  enlargement.  He  finds  small  infiltrations,  fre- 
quently repeated,  to  be  best.  To  avoid  all  chance  of  inducing 
acute  hyperthyroid  symptoms  with  the  earlier  injections,  Wat- 
son makes  preliminary  injections  of  a  few  minims  of  sterile 
saline  solution  at  1  to  3  days'  intervals,  followed  by  injections  of 
sterile  water.  Cases  responding  best  are  those  of  beginning 
hyperthyroidism.  Where  such  treatment  fails,  thyroidectomy, 
or  at  least  ligation  of  some  of  the  thyroid  arteries,  may  be 
resorted  to. 

Hypothyroid  Degenerative  Goiter.  This  type  of  goiter 
often  results  from  the  occurrence  of  some  form  of  degenera- 
tion in  a  simple,  parenchymatous  enlargement.  The  degenera- 
tive change  may  be  limited  to  one  or  several  restricted  por- 
tions of  the  gland,  thus  causing  it  to  present,  in  most  instances, 
an  irregular  or  nodular  surface.  The  latter  peculiarity  is  thus 
the  chief  feature  clinically  distinguishing  the  degenerated  from 
the  simple,  parenchymatous  goiter.  Again,  in  the  latter,  pres- 
sure from  the  outside  reduces  the  size  of  the  enlargement, 
causing  vascular  depletion,  while  nodular  goiters  yield  but 
little  to  pressure.  In  large  colloid  or  cystic  "growths,  fluctua- 
tion may  sometimes  be  discerned.  Pressure-symptoms,  due 
to  nodular  formations  enclosed  in  the  goiter,  are  far  more 
likely  to  exist  in  the  degenerative  than  in  simple  goiters,  such 
symptoms  comprising  hoarseness,  dyspnea,  paralysis  of  the 
vocal  cords,  cyanosis,  paralysis  of  various  muscles  of  the  arm, 
numbness  of  the  fingers,  etc.  Myxedematous  symptoms  may 
be  noted  when  fibrous  or  other  retrogressive  changes  have 
been  sufficient  to  cut  down  almost  completely  the  functional 
activity  of  the  gland. 

Among  the  varieties  of  degenerative  goiter  are  the  colloid, 
cystic,  and  fibrous  forms.  With  this  group  may  likewise  con- 
veniently be  mentioned  intrathoracic  and  constrictive  goiters, 
lingual  goiter,  and  hemorrhagic  goiter. 


124  DISEASES    OF    THE    DUCTLESS    GLANDS. 

Treatment.  As  in  other  forms,  of  goiter,  detection  and  re- 
moval of  a  causative  intoxication  is  essential,  though  since  the 
degenerative  processes  mentioned  are  often  later  changes  in 
the  enlarged  gland,  complete  results  are  not  as  frequently  to 
be  expected  as  in  simple,  parenchymatous  goiter.  lodin  or 
thyroid  substance  may  in  the  colloid  form  give  rise  to  un- 
toward eft'ects,  but  in  most  of  the  other  t\'pes  referred  to  ma}" 
be  administered,  carefully  and  tentatively.  Cases  of  long 
standing,  even  though  the  goiter  be  small,  are  those  most 
likely  to  react  unfavorably  to  iodin.  In  the  cystic  goiters, 
aspiration  of  the  cysts  may  greatly  hasten  reduction  of  the 
gland. 

Surgical  treatment  of  the  simple,  parenchymatous  type  of 
goiter,  or  of  the  degenerative  types,  is  indicated  where,  upon 
fair  trial  of  non-operative  measures,  no  results  are  obtained. 
In  general,  the  following  specific  indications  for  operation  are 
recognized:  (1)  disfigurement,  where  the  growth  is  large; 
(2)  symptoms  from  pressure  on  the  trachea,  esophagus,  larv-nx, 
or  other  structures  in  the  neck  or  upper  thorax;  (3)  rapid 
enlargement,  suggesting  a  malignant  nature ;  (4 )  symptoms 
of  hj'perthyroidism,  if  not  relieved  by  boiling  water  or  quinin 
and  urea  injections;  (5)  infection  of  the  goiter. 

Often  a  definite  indication  for  operation  consists  rather 
in  some  special  location  of  the  simple  or  degenerated  goiter- 
tissue  than  in  the  size  of  the  enlargement  as  a  whole.  At 
times  a  swelling  not  exceeding  a  cherry  in  size  may  cause 
urgent  discomfort.  Especially  in  intrathoracic  goiter  w4th 
pressure-symptoms — difficult  to  recognize  unless  the  A*-rays 
be  used — is  earlv  intervention  indicated.  Colloid  and  adeno- 
matous goiters,  usually  but  slightly  responsive  to  medical 
treatment,  require  operation  in  the  presence  of  pressure-symp- 
toms, the  diseased  part  of  the  gland  being  removed  and  its 
better  portions  preser\'ed.  In  the  simple  goiter  of  adolescents, 
which  tends  to  subside  later  in  life,  operation  is  seldom 
indicated. 

Xodular  or  cystic  goiters,  or  goiters  beginning  to  adhere 
to  neighboring  structures,  demand  operation,  according  to 
most  surgeons.  A\'here  both  lobes  are  enlarged,  the  larger  and. 
especially,  the  deeper  lobe  is  the  one  to  be  removed.  After  a 
unilateral  operation  the  remaining  lobe,  it  is  said,  will  later 


DISEASES    OF    THE    THYROID.  125 

undergo  a  reduction  in  size.  If  a  bilateral  enlargement  is  sym- 
metrical, however,  C.  II.  Ma3'oi--'  favors  division  of  the 
isthmus,  with  doul)le  resection  of  the  gland,  as  being  indicated 
for  the  best  cosmetic  results.  As  E.  H.  Pooli^-i  points  out,  it 
is  advantageous,  though  not  imperative,  to  leave  in  situ  the 
posterior  portions  of  both. lateral  lobes,  in  relation  with  each 
of  which  a  recurrent  laryngeal  nerve  and  two  parathyroids 
usually  lie. 

Some  thyroid  nodules,  e.g.,  adenomata,  are  encapsulated, 
and  can  be  removed  by  perforation  of  the  gland  substance  and 
enucleation  of  the  nodule  with  the  finger  or  a  blunt  instrument. 
Resection-enucleation,  applicable  in  large  adenomata,  con- 
sists in  excising-  the  thin  layer  of  thyroid  tissue  over  the 
tumor  along-  with  the  latter,  and  then  suturing-  the  cut  edges 
of  the  gland.  In  rapidly  g-rowing-  parenchymatous  goiter  in 
young  subjects,  arterial  ligation  has  been  advised. 

In  operations  for  uncomplicated  simple  goiter  the  mortal- 
ity is  only  a  fraction  of  1  per  cent.  Operation  is  safest  where 
the  growth  is  rounded  and  even  in  outline — typically  in  cystic 
goiter.  Risk  is  greater,  however,  where  continued  pressure  on 
the  trachea  has  resulted  in  bronchitis,  emphysema,  poor  oxy- 
genation, and  impaired  heart-action.  Diffuse  follicular  colloid 
degeneration  is  also  an,  unfavorable  condition,  the  proportion 
of  normal  gland-tissue  having  been  greatly  reduced.  In  large, 
nodulated  goiters,  pressing  on  the  trachea  and  only  slightly 
movable,  vascular  ligation  followed  by  unilateral  excision  is 
deemed  the  safest  procedure. 

Malignant  Goiter.  Malignant  goiter  usually  occurs  as  a 
complication  of  simple  goiter  of  long  standing,  but  occasion- 
ally is  primary.  Sarcoma  is  much  less  common  than  carcinoma. 
Pain  in  an  uninflamed  goiter  suggests  malignancy,  especially 
if  a  cachectic  facies  coexists.  The  lymphatics  are  involved 
early,  as  a  rule,  and  the  metastases  show  a  predilection  for  the 
bones.  Carcinoma  of  the  thyroid  is  usually  nodular ;  sarcoma, 
smooth.  Occasionall}^  accessory  thyroid  glands,  situated  be- 
tween the  trachea  and  esophagus  or  behind  the  latter,  develop 
malignancy. 

Treatment.  Early  operation  is  indicated,  the  whole  gland 
being  removed,  but  its  capsule  preserved  whenever  possible. 
In  late  malignancy  with  lymphatic  involvement,  operation  is 


126  DISEASES   OF   THE   DUCTLESS   GLANDS. 

hardly  to  be  recommended,  except  for  the  reHef  of  pressure 
symptoms,  as  it  may  accelerate  the  growth  of  the  tumor. 

Congenital  Goiter.  Diethlin,  among-  2292  cases  of  goiter, 
met  with  no  less  than  25  cases  during  the  first  year  of  life,  and 
other  authors  have  reported  a  much  larger  ratio.  In  some 
infants  the  goiter  is  purely  congestive,  being  due  presumably 
to  pressure  during  parturition.  In  many  more  instances,  how- 
ever, it  is  of  the  parenchymatous  type,  and  the  child  is  the 
offspring  of  a  goitrous  mother.  JMcCarrison,!--"^  from  experi- 
mental work,  has  become  convinced  that  congenital  goiter  is 
due  to  the  effects  of  toxic  substances  derived  from  the  ma- 
ternal intestine  upon  the  fetal  thyroid. 

In  a  goitrous  infant  sudden  death  may  occur  soon  after 
birth.  At  times  the  clinical  signs,  with  the  exception,  perhaps, 
of  a  slight  swelling  at  the  front  of  the  neck,  do  not  appear 
until  several  weeks  or  more  after  birth.  The  symptoms  are 
practically  those  observed  in  adults.  Congestive  goiter  from 
pressure  may  disappear  permanently  within  twenty-four  hours, 
or  reappear  intermittently. 

Treatment.  The  various  forms  of  artificial  respiration,  to- 
gether with  the  use  of  oxygen,  are  helpful.  If  dyspnea  per- 
sists, section  of  the  isthmus,  or  exothyropexy,  will  give  imme- 
diate relief.  Tracheotom}'  is  contraindicated,  though  intuba- 
tion has  been  employed.  Thyroid  substance  or  sodium  iodid 
given  to  the  mother  may  at  times  lead  to  disappearance  of  the 
goiter  in  both  mother  and  child.  In  the  congestive  form,  cold 
compresses  should  be  applied  to  the  neck,  and  warm  foot- 
baths or  hot  baths  administered. 

DISEASES  OF  THE  PARATHYROIDS. 

The  parathyroid 'glandules  develop  in  pairs  from  the  third 
and  fourth  branchial  clefts  on  either  side  of  the  body,  and  are 
thus  typically  four  in  number — two  superior  and  two  in- 
ferior. In  some  human  cadavers,  however,  even  careful  study 
of  serial  sections  has  at  times  failed  to  reveal  more  than  two  or 
three  of  the  glandules.  The  superior  parathyroids  generally 
lie  behind  the  middle  third  of  the  thyroid,  at  the  level  of  the 
lower  border  of  the  cricoid  cartilage ;  the  inferior,  behind  the 
lower  third  of  the  thyroid.     At  times  an  inferior  parathyroid 


DISEASES    OF   THE    PARATHYROIDS.  127 

is  situated  at,  or  even  below,  the  lower  pole  of  the  thyroid. 
Only  rarely  is  a  parathyroid  embedded  in  thyroid  tissue  ;  usu- 
ally, they  are  surrounded  by  fillers  of  the  thyroid  capsule,  and 
cling-  to  the  latter  when  it  is  stripped  from  the  thyroid.  Small 
supernumerary  parathyroids  have  been  noted,  generally  below 
the  thyroid,  or  within  the.  thymus  or  the  thyroid  itself. 

Each  parathyroid  is  constituted  of  a  compact  mass  of  epi- 
thelial cells,  tog'ether  with  a  reticular  stroma.  In  occasional 
instances  the  epithelia  are  formed  into  lobules,  in  the  center' 
of  which  a  lumen  filled  with  colloid  may  be  found.  The  epi- 
thelia are  divided  into  two  types,  the  more  numerous  principal 
cells  and  a  minority  of  the  oxyphile  or  granular  cells.  The 
latter,  it  has  been  sug'gsted,  are  functionating  cells,  and  the 
clear  elements,  cells  in  a  resting'  state.  As  regards  proteid 
contents,  Beebe^^o  notes  that,  whereas  the  thyroid  contains  an 
especially  large  amount  of  globulin,  the  parathyroids  contain 
chiefly  nucleoproteid. 

The  blood  supply  of  the  parathyroids  is  derived  chiefly 
from  the  inferior,  less  from  the  superior  thyroid  arteries. 
Anastomoses  may  also  bring  blood  from  the  tracheal,  esoph- 
ageal, and  pharyngeal  vessels.  Nerve  fibers  ending  in  imme- 
diate relationship  with  the  vessels  to  the  parathyroids  have 
been  shown  to  exist  by  Rhinehart. 

Whereas  removal  of  the  thyroid  alone  is  followed  by  a 
prolonged  post-operative  life,  thyroparathyroidectomy,  or 
parathyroidectomy  alone,  results  in  severe  nervous  symp- 
toms— tetany — soon  terminating  in  death.  The  morbid  effects, 
characterized  especially  by  a  tendency  to  spasms  or  convul- 
sions, usually  begin  about  twenty-four  hours  after  removal  of 
all  the  parathyroids,  death  g-enerally  following'  in  three  to 
five  days.  In  dogs,  a  single  parathyroid  suffices  in  most  in- 
stances to  obviate  tetany,  but  in  some  animals  even  removal 
of  onl)'-  two  parathyroids  out  of  four  has  been  observed  to  in- 
duce the  disease. 

Functionally,  according  to  some  observers,  the  parathy- 
roids operate  independently  of  the  thyroid.  This  view  is  sug- 
gested by  the  differences  in  the  efifects  of  removal  of  the  two 
types  of  tissue.  Various  facts,  however,  tend  to  show  that  the 
independence  of  the  two  organs  is  not  as  complete  as  might 
be  supposed.     Thus,  some  evidence  has  been  collected  to  the 


128  DISEASES    OF   THE    DUCTLESS    GLANDS. 

effect  that  after  thyroidectom}-  the  parathyroids  ma}'  assume 
in  some  degree  the  functions  of  the  thyroid.  As  shown  by 
Vassale,  moreover,  injection  of  thyroid  extract  is  capable,  like 
parathyroid  extract,  of  alla^'ing  the  convulsive  disorders  which 
follow  complete  parathyroidectomy.  According  to  Edmunds, 
extirpation  of  the  parathyroids  causes  hypertrophic  histo- 
logical changes  in  the  thyroid.  Vassale  and  Generali^-" 
found  that  after  death  from  parathyroidectomy  the  thyroid 
contains  no  colloid,  thus  suggesting  that  the  formation  of  the 
thyroid  product  is  in  some  way  related  to  the  functions  of  the 
parathyroids.  In  experiments  performed  by  Gley,!-^  an  ap- 
parently complete  parathyroidectomy,  with  partial  thyroidec- 
tomy, did  not  prove  fatal  until  the  remaining  lobe  of  the  thy- 
roid was  likewise  removed. 

Again,  it  has  been  asserted  that  grafted  pure  th3'roid  tissue 
is  capable  of  assuming  the  functions  of  both  the  thyroid  and 
the  parathyroids,  thus  arresting  the  convulsive  disorders 
caused  by  parathyroidectomy,  and  preventing  death.  Tan- 
bergi29  noted  that  if  insufficiency  of  the  parathyroids  was  in- 
duced in  meat-fed  animals  by  extirpation  of  two  or  more  of 
the  glandule^  the  usual  hypertrophy  of  the  thyroid  due  to  the 
meat  diet  did  not  develop.  Further,  thyroid  hypertrophy  in- 
duced by  a  meat  diet  disappeared  after  excision  of  a  sufficient 
number  of  parathyroids.  This,  according  to  Tanberg,  points 
to  some  interrelation  between  the  thyroid  and  parathyroid 
glands,  at  least  to  the  extent  that  parathyroid  insufficiency  in- 
terferes with  the  function  of  the  thyroid.  Gley's  conception 
of  the  relationship  of  the  two  structures  recognizes  a  functional 
association  in  the  sense  that  one  organ  ser\'es  to  complete  the 
work  of  the  other.  According  to  Sajous,  Sr.,i-5o  the  secretion 
of  the  parathyroids,  passing  into  the  lymph  spaces  with  that 
of  the  thyroid,  eventually  reaches  the  heart  and  general  blood- 
stream, and,  like  the  thyroid  product,  becomes  a  constituent 
of  the  hemoglobin.  The  combined  thyroparathyroid  products 
thereupon  serve  to  enhance  general  oxidation  "by  increasing, 
as  a  ferment,  the  vulnerability  of  the  phosphorus,  which  all 
cells,  particularly  their  nuclei,  contain,  to  oxidation  by  the  ad- 
renoxidase  in  the  blood."  The  parathyroid  secretion  is  also 
deemed  by  him  to  co-operate  with  the  thyroid  secretion  in  in- 
creasing the  germicidal  and  antitoxic  properties  of  the  blood. 


DISEASES    OF    THE    PARATHYROIDS.  129 

Removal  of  the  parathyroids  was  found  by  Jeandelize/^i 
like  thyroidectomy,  to  lower  the  body  temperature.  That  the 
parathyroids,  moreover,  are  in  a  sense,  like  the  thyroid,  pro- 
tective and  antitoxic  organs  is  indicated  by  the  effects  of  their 
removal,  the  resulting  convulsive  phenomena  strongly  suggest- 
ing a  capacity  on  the  part  of  the  parathyroids  to  destroy  or 
prevent  the  morbid  action  of  certain  spasmogenic  poisons. 
Further  evidence  in  favor  of  such  a  conception  is  afforded  by 
the  fact  that  the  blood  and  urine  of  parathyroidectomized  dogs 
have  been  found  by  Rogowitsch  and  others  to  cause  convul- 
sions in  normal  animals.  The  observation  that  injection  of 
parathyroid  extract  will  arrest,  at  least  temporarily,  the  con- 
vulsive phenomena  of  parathyroidectomy  has  generally  been 
accepted  as  proof  that  some  antitoxic  substance  is  contributed 
to  the  blood  by  the  parathyroids.  MacCallum  and  Voegtlin^ss 
having  found  that  calcium  salts  arrest  tetany  due  to  parathy-  ■ 
roidectomy,  the  antitoxic  action  of  the  parathyroids  has  been 
ascribed  to  some  influence  exerted  by  them  on  calcium  metab- 
olism. This  question  will  be  further  taken  up  under  the  head- 
ing of  Parathyroid  Insufficiency.  According  to  Kendall, ^^s 
who,  as  we  have  seen  under  Diseases  of  the  Thyroid,  has  ad- 
vanced the  hypothesis  that  the  function  of  the  thyroid  is  to 
regulate  the  deaminization  of  amino-acids,  the  parathyroid 
function  is  to  detoxicate  the  ammonium  carbonate  formed  by  • 
union  of  the  removed  amino-group  with  the  carbon  dioxid  in 
the  blood.  He  states  that,  from  the  results  of  previous  in- 
vestigators, it  seems  probable  that  ammonium  carbonate  is 
responsible  for  the  tetany  following  parathyroidectomy. 

No  group  of  phenomena  characteristic  of  excessive  para- 
thyroid activity  being  as  yet  known,  consideration  of  the  mor- 
bid conditions  of  the  parathyroids  comprises  chiefly  a  discus- 
sion of  tetany  or  other  manifestations  of  parathyroid  insuffi- 
ciency and  of  tumors  of  the  parathyroids. 

PARATHYROID  INSUFFICIENCY   (HYPO- 
PARATHYROIDIA). 

Postoperative  Tetany.  The  convulsive  phenomena  fol- 
lowing complete  parathyroidectomy  range  from  a  mere  tend- 
ency to  spasm  to  violent  tetanic  or  epileptoid  paroxysms,  with 


130  DISEASES    OF   THE    DUCTLESS    GLANDS. 

foaming  at  the  mouth,  and  finally  death  from  "cramp  as- 
phyxia." Fibrillary  tremors  are  also  a  marked  feature,  and, 
as  in  strvxhnin  poisoning,  the  convulsive  phenomena  are  easily 
initiated  by  even  mild  peripheral  sensory  stimuli.  The  tem- 
perature rises  during  the  convulsive  paroxysms,  but  falls  con- 
siderably below  normal  during  the  intervals.  Oxygenation  is 
plainly  impaired,  and  the  general  condition  is  one  of  weakness 
and,  as  a  rule,  somnolence.  Pruritus  is  a  manifest  symptom. 
The  heart-beat  is  rapid,  except  after  convulsions,  and  the 
respirations  are  greatly  accelerated.  Death  occurs  more  fre- 
quently during  the  state  of  depression  following  a  period  of 
hyperexcitability  and  convulsions  than  during  an  attack  of 
hyperexcitability. 

In  man,  tetany  has  at  times  resulted  from  accidental  re- 
moval of  an  excessive  amount  of  parathyroid  tissue  during 
thyroidectomy.  As  a  rule,  beginning  trismus  and  facial  twitch- 
ings  and  tingling  are  the  initial  symptoms.  The  extremities 
are  then  affected,  the  hands  assuming  the  "main-en-griffe"  or 
"obstetric"  positions,  the  forearms  becoming  flexed,  and  the 
feet  being  cramped,  often  in  the  equinovarus  position.  In 
severe  cases,  opisthotonos  may  develop,  respiration  become 
difficult,  and  the  circulation  impaired.  As  a  rule,  the  first 
signs  occur  on  the  third  or  fourth  day  after  the  operation. 
The  paroxysms  vary  in  frequency  from  one  to  many  a  day. 
Where  the  parath3^roids  have  been  merel}^  injured  during  the 
operation,  tetany  ceases  as  repair  takes  place. 

Tetany,  usually  in  a  milder  form,  is  also  met  with  clinically 
as  a  result  of  various  lesions  or  intoxications  of  the  parathy- 
roids. These  non-operative  forms  of  hypoparathyroid  tetany 
will  be  referred  to  under  the  heading  Organic  and  Functional 
Disorders  of  the  Parathyroids. 

During  tetany  following  removal  of  the  parathyroids  the 
irritability  of  the  peripheral  nerves  and,  apparently,  of  all 
other  nervous  tissue  to  the  galvanic  current  is  greatly  increased. 
Intravenous  injection  of  soluble  salts  of  calcium  having  been 
showm  almost  instantly  to  remove  this  excessive  irritability, 
MacCallum  and  Voegtlin^s^  were  led  to  formulate  the  hypo- 
thesis that  the  function  of  the  parathyroids  is  in  some  way  to 
control  calcium  metabolism,  and  that  after  parathyroidectomy 
the  body  fluids  and  soft  tissues  are  deprived  of  soluble  cal- 


DISEASES   OF   THE    PARATHYROIDS.  131 

cium,  this,  in  turn,  resulting-  in  the  abnormal  nervous  irritabil- 
ity of  tetany.  The  observation  of  D.  W.  Wilson,  Stearns,  and 
their  co-workers,^'"''  however,  that  parathyroidectomy  is  soon 
followed  by  an  alkalosis,  and  the  facts  that  hydrochloric  acid 
is  equal  in  therapeutic  power  to  calcium  in  experimental 
teta;ny,  and  that  continuous  administration  of  calcium  is  not 
capa1)le  of  preventing  death  permanently  after  parathyroidec- 
tomy, are  complicating-  factors,  which  led  Voegtlin^-^'''  to 
recognize  the  probability  that  the  parathyroids  have  other 
functions  besides  their  influence  on  calcium  metabolism,  and  the 
possibility  that  tetany  is  but  a  partial  expression  of  the 
metabolic  disturbances  induced  by  removal  of  these  organs. 
Kendall's^^'^  view  of  the  causation  of  tetany  has  already  been 
mentioned. 

Kochiss  asserts  that  after  parathyroidectomy,  methyl 
cyanamide  accumulates  in  the  body,  and  is  responsible  for  the 
death  of  the  animals. 

Treatment.  Calcium  lactate  was  found  of  some  value  in 
tetany  by  MacCallum  and  Voegtlin.  It  should  be  given  in  full 
dosage,  at  least  0.6  gram  (10  gr.)  every  hour  or  two,  or  by  rec- 
tum in  larger  doses  in  saline  solution.  Absorption  of  calcium 
salts  from  the  alimentary  tract  being,  however,  slow  at  best, 
while  subcutaneous  and  intramuscular  injections  of  such  salts 
cause  marked  irritation,  intravenous  use  is  by  far  the  best  pro- 
cedure in  emerg'ency  cases.  Winternitz,i39  for  example,  thus 
gave  100  mils  (3%  f^)  of  a  4  per  cent,  solution  in  a  non-opera- 
tive case  of  tetany,  with  satisfactory  results.  Marked  benefit 
from  calcium  treatment  lasts,  however,  but  about  twenty-four 
hours,  or  somewhat  longer,  after  which  the  tetany  symptoms 
begin  to  return,  growing  progressively  worse  thereafter. 

Benefit  from  the  oral  use  of  parathyroid  extracts  appears  to 
be  only  slight,  MacCallum  finding  that  large  quantities  were 
necessary  to  give  any  result.  Much  more  effective  is  the  sub- 
cutaneous use  of  an  extract  of  fresh  parathyroids.  Bran- 
tham,!'**^  in  preparing  such  an  extract,  placed  5  fresh  beef  para- 
thyroids in  1 :  1000  mercuric  chlorid  solution  for  ten  minutes, 
then  cut  them  into  pieces  aseptically,  and  g-round  them  in  a 
mortar  with'  400  mils  (13  oz.)  of  sterile  saline  solution.  The 
product  was  finally  filtered  through  gauze,  and  infused  under 
the  patient's  breast. 


132  DISEASES    OF   THE   DUCTLESS    GLANDS. 

As  with  calcium,  relief  from  parath}'roid  extract  is  only 
evanescent.  Transplantation  of  parathyroid  tissue  suggests 
itself  as  a  possible  means  of  avoiding  this.  While  Halsted 
found,  however,  that  autotransplantation  of  parathyroids  is 
feasible  in  the  presence  of  hypoparathyroidia,  transplantation 
from  other  individuals  has  apparently  never  been  thoroughly 
successful,  the  implant  causing  improvement  for,  e.g.,  a  couple 
of  weeks  (a  result  sometimes  sufficient  to  save  life  by  tiding  a 
case  over  a  critical  period  of  parathyroid  deficiency),  then 
becoming  absorbed. 

In  the  diet,  in  the  presence  of  hypoparathyroidia,  it  is  ad- 
vantageous to  exclude  meats  and  other  substances  rich  in 
Oiucleins,  to  minimize  the  formation  of  spasmogenic  wastes. 
Water  should  be  taken  freely  for  eliminatory  purposes.  Com- 
plete rest  tends  to  reduce  the  number  and  severity  of  the 
paroxysms. 

Organic  and  Functional  Disorders  of  the  Parathyroids. 
IMild  forms  of  tetany  sometimes  result  from  partial  lesions  of 
the  parathyroids,  such  as  tuberculosis,  interstitial  hemorrhage, 
etc.  Chvostek's  sign  (facial  spasm  upon  tapping  the  facial 
nerve),  Hoffmann's  sign  (hyperesthesia  upon  percussion  of 
sensor}'-  nerves),  etc.,  are  clinically  evidences  of  the  existence  of 
tetany.  Infectious  diseases  may  be  primary  causes  of  tetany 
through  injury  to  the  parathyroids.  Tetany  is  probably  also 
at  times  a  result  of  excessive  demand  upon  and  exhaustion  of 
the  parathyroid  function,  or  of  inhibition  of  the  activity  of  the 
g'landules  through  the  action  of  circiilating  toxic  materials 
upon  them.  Whether  tetany  accompanying  gastro-intestinal 
disturbances,  uremia,  &nd  violent  excitement  or  exertion  may 
be  due  to  parathyroid  insufficiency  is  not  as  yet  definitely 
established.  That  tetany  during  pregnancy  and  lactation 
(usually  the  former)  may  be  due  to  excessive  functional  de- 
mand upon  the  parathyroids  is  suggested  by  the  observation 
of  V^assale  and  General!,  and  many  others,  that  after  partial 
removal  of  the  parathyroids  tetany  during  pregnancy  will  not 
infrequently  follow.  Parathyroid  disease  has  been  thought  a 
factor  in  the  pathogenesis  of  paralysis  agitans,  in  which  lesions 
of  the  glandules  have  sometimes  been  found  and  considerable 
improvement  procured  by  parathyroid  therapy.  Harbitzi^i 
has  reported  2  cases  of  tumors  of  the  parathyroid,  1  associated 


DISEASES    OF    THE   THYMUS.  133 

with  osteomalacia,  and  the  other  with  paralysis  agitans.  He 
states  that  of  the  few  cases  of  parathyroid  tumor  recorded,  few 
have  presented  symptoms  bearing-  on  the  functions  of  these 
glands. 

Treatment.  In  the  presence  of  signs  of  parathyroid  insuffi- 
ciency, the  measures  described  under  Postoperative  Tetany  are 
indicated.  In  paralysis  agitans,  protracted  benefit  has  been 
reported  by  Berkeleyi'*^  from  the  administration  of  parathy- 
roid nucleoproteid,  prepared  by  the  Beebe  process,  in  doses 
of  20  drops  a  day.  Dried  parathyroids  in  the  daily  dosage  of 
5  to  7  capsules,  each  equivalent  to  0.03  gram  (^  gr.)  of  the 
fresh  glandules,  may  also  be  used. 

DISEASES  OF  THE  THYMUS. 

The  thymus  gland  was  shown  by  Hammari'*^  to  increase 
in  size  from  birth  to  puberty,  at  which  time  its  average  weight 
is  25  grams.  It  then  diminishes  in  size,  at  first  rapidly,  weigh- 
ing 5  grams  at  the  twenty-fifth  year,  then  more  slowly  to  50 
or  65  years,  when  it  may  weigh  but  0.73  gram.  Even  in  old 
age,  however,  it  usually  retains  small  remnants  of  parenchyma. 
AVide  and  rapid  fluctuations  in  the  weight  of  the  thymus  may 
occur  at  any  time  through  starvation,  exhaustion,  or  wasting 
diseases. 

Histologically  the  thymus  is  deemed  primarily  an  epi- 
thelial structure  invaded  by  lymphocytes  from  neighboring 
mesenchyme,  these  lymphocytes  then  so  proliferating  as  to 
constitute  the  main  mass  of  thymus  tissue,  through  which 
course  as  a  reticulum  the  epithelial  cells.  Careful  study  has 
shown  that  the  thymic  lymphocytes  are  very  similar,  if 'not 
identical,  with  those  found  in  lymph  glands.  Biedli"*4  recog- 
nizes a  difiference,  however,  in  that  the  amount  of  nucleinates 
is  at  least  five  times  as  large  in  the  thymus  as  in  the  lymph 
glands.  The  thymus  is  thus  apparently  an  organ  capable  of 
supplying  nucleins,  bodies  which  are  rich  in  phosphorus,  to 
the  body  at  large.  "The  more  one  studies  the  thymus,"  states 
Pappenheimer,i45  "the  more  certain  becomes  the  conviction 
that  the  constant,  and  under  some  conditions,  excessive  dis- 
integTation  of  nuclear  material  is  the  most  obvious  form  of 
activity  which  takes  place  in  this  organ." 


134  DISEASES    OF    THE    DUCTLESS    GLANDS. 

That  deficient  thymus  activity  might  react,  during  the 
period  of  growth,  upon  the  various  structures  of  the  body 
most  rich  in  phosphorus-containing  material  is  a  permissible 
supposition  in  view  of  the  above  facts.  Huiskampi'*^  found 
nucleohiston,  which  contains  no  less  than  Z.7  per  cent,  of  phos- 
phorus, to  be  the  most  abundant  proteid  in  the  thymus.  Ex- 
amining the  results  of  experimental  thymectomy  in  the  hands 
of  various  experimenters,  one  notes  that  the  changes  observed 
as  a  result  of  this  operation  in  many  instances  correspond 
rather  closely  with  those  to  be  expected  from  lack  of  phos- 
phorus distribution  in  the  system. 

The  labors  of  Basch  (1906),  Klose  and  Vogt  (1910),  Lampe 
(1913),  and  others  seemed,  until  recently,  to  have  definitely 
shown  that,  e.g.,  in  dogs  completely  thymectomized  in  early 
life,  bone  deformities  of  a  rachitic  type  appear  about  the  fourth 
month.  The  paws  become  curved  inward,  and  the  cranium 
is  stated  to  be  large,  flat,  and  short.  Toward  the  fifth  month 
the  animal  becomes  somnolent,  depressed,  and  cachectic,  los- 
ing Aveight  until,  between  twelve  and  eighteen  months  later, 
coma  and  death  supervene.  More  recently,  Nordmann,!^'''  and 
Rowland,  McClure  and  Park,i'*8  {^  experiments  which  appear 
to  have  been  performed  with  great  care,  have  failed  to  repro- 
duce these  results,  and  Pappenheimer^^^  has  been  led  to  con- 
clude that  loss  of  the  thymus  in  young  animals  is  not  of  prime 
importance,  but  is  readily  compensated  for  in  ways  not  yet 
understood. 

The  large  number  of  previous  positive  results  seem  suffi- 
ciently conclusive  for  the  present.  The  possibility  suggests 
itself,  moreover,  that  the  experimental  discrepancies  may  have 
been  due  to  different  feeding  methods  in  dififerent  series  of  ex- 
periments ;  were  the  diet  relatively  poor  in  phosphorus,  the 
thymus  deficiency  might  lead  to  distinct  manifestations  where 
a  richer  diet  would  cause  no  disturbances  whatever.  If  the 
thymus  is  considered,  as  is  manifestly  the  case,  only  one  of  a 
number  of  reservoirs  or  factories  for  phosphorus-containing 
bodies,  it  can  readily  be  understood  that  under  different  cir- 
cumstances the  thymus  deficiency  might  vary  enormously. 
Were  enough  of  these  bodies  for  existing  needs  stored  or 
elaborated  elsewhere,  thymectomy  might  be  entirely  devoid 
of  effect,  at  least  in  relation  to  the  osseous  system. 


DISEASES    OF    THE    THYMUS.  135 

In  the  human  subject  in  particular,  certain  findings  seem  to 
suggest  a  relationship  between  thymus  deficiency  and  the 
production  of  idiocy.  At  Bicetre  Hospital,  according  to 
Morel,i^*o  75  per  cent,  of  408  non-myxedematous  idiotic  chil- 
dren examined  post-mortem  showed  absence  of  the  thymus.  In 
28  mentally  weak  children  examined  by!  Bourneville,  the  thy- 
mus was  likewise  absent.  Basch,  Klose  and  Vogt,  Morel  and 
others  observed  marked  mental  impairment  in  puppies  in  the 
fifth  or  sixth  month  after  thymectomy.  A  possible  influence 
of  the  thymus  on  the  growth  of  the  body  as  a  whole  is  indi- 
cated by  Gudernatsch's^^i  observation  that  feeding  thymus 
substance  to  tadpoles  greatly  prolongs  their  early  growth 
period,  the  tadpoles  becoming  unduly  large,  but  metamor- 
phosis into  frogs  being,  on  the  other  hand,  correspondingly 
delayed.  R.  W.  Wilcox^^^  claims  to  have  obtained  a  gain  in 
height  of  9^  inches  in  an  undersized  boy  by  administration  of 
thymus.  According  to  some,  thymectomy  causes  delayed  and 
defective  development  of  the  reproductive  organs.  The  ex- 
periments of  various  observers  on  this  point  have,  however, 
been  very  contradictory. 

On  the  whole,  as  a  provisional  conclusion,  it  may  be -stated 
that  there  is  considerable  evidence  at  hand  tending  to  confirm 
the  view  advanced  by  Sajous,  Sr.,i^3  ^h^t  the  function  of  the 
thymus  is  to  supply,  through  the  agency  of  its  lymphocytes, 
the  excess  of  phosphorus  in  organic  combination  which  the 
body  requires  during  the  developmental  period. 

THYMUS  INSUFFICIENCY  (HYPOTHYMIA). 

Under  various  conditions,  such  as  acute  or  chronic  inani- 
tion, infectious  processes,  and  the  influence  of  the  .f-rays,  a 
premature  involuton  of  the  thymus  may  occur.  Pappen- 
heimer^'^'*  speaks  of  a  massive  destruction  of  the  thymus 
lymphocytes  as  occurring  under  such  conditions,  and  remarks 
on  the  "extraordinary  fragility"  of  these  cells,  which  leads  to 
a  "dissolution  of  nuclear  material  en  masse."  Various  experi- 
menters have  recorded  an  unusual  susceptibility  of  the  body 
to  infection  after  thymectomy,  Hart  and  Nordmann^^s  recog- 
nizing that  the  organ  takes  an  active  part  in  the  resistance  of 
the  organism  to  infection.     Especially  important,  according  to 


136  DISEASES    OF    THE    DUCTLESS    GLANDS. 

Sajous,  Sr.,^5^  is  the  relationship  of  thymus  insufficiency  to 
certain  forms  of  deficient  mental  development,  in  particular 
Mongolian  idiocy. 

Mongolian  Idiocy.  In  this  condition  are  combined  the 
typicallv  ^Mongolian  slant  of  the  eyes  and  prominent  epican- 
thal  folds,  with  various  defects  in  bone  development  resemb- 
ling those  reported  in  thymectomy  experiments  in  animals. 
The  stature  is  low — the  long  bones,  particularly  those  of  the 
legs,  being-  abnormally  short;  the  chest  is  flat;  the  nose 
squatty,  the  ears,  small  and  undeveloped;  and  the  hands 
stubby  and  square,  with  the  fingers  short,  but  tapering.  The 
head  as  a  whole  appears  unusually  rounded,  and  is  small  in 
size,  and  further  evidence  of  defective  bone  nutrition  is  mani- 
fest in  the  frequency  of  rickets,  of  which  distinct  signs  are,  as 
a  rule,  noticeable  at  birth.  Palatal  deformities  exist  in  about 
tAvo-thirds  of  the  cases.  Appearance  of  the  teeth  of  both  den- 
titions is  delayed ;  the  teeth  are  irregular,  and  soon  undergo 
caries. 

"\Miereas  the  bony  conditions  just  mentioned  suggest  de- 
ficiency of  the  thymus,  the  dry  and  rough  skin  of  certain  cases, 
and  the  thick,  heavy,  protruding  tongue,  seem  indications  of 
hypotli}-roidia.  Hypothermia.  Avith  marked  sensitiveness  to 
cold  and  sluggish  circulation,  is  also  a  significant  feature.  Re- 
laxation of  the  general  musculature,  voluntary-  and  involun- 
tary, as  well  as  of  the  ligaments,  is  commonly  noted.  The 
relative  insufficiency  of  the  thymus  and  thyroid  glands,  and 
possibly  also  of  the  adrenals,  in  this  disease  render  the  ]\Ion- 
golian  subjects  peculiarly  susceptible  to  infections.  As  a  mat- 
ter of  fact,  respiratory  and  intestinal  infections  form  such  an 
obstacle  to  continued  life  in  these  cases  that  the  twent3^-fifth 
year  is  reached  in  but  9.4  per  cent,  of  them  ( AMggandt). 

Deficiency  in  the  nucleins  normally  supplied  bv  the  thymus 
may  account  for  the  extremely  slow  mental  development  of 
the  tA'pical  ^Mongolian  idiot.  Abnormal  quiet  and  greatly  post- 
poned appearance  of  the  powers  of  observ^ation  are  typical 
throughout,  though  these  children  are  apt  to  be  amiable  in 
temper,  and  show  a  marked  predilection  for  ape-like  mimicry 
as  well  as  for  music.  Leeper.^-"''  in  a  study  of  176  Mongolian 
idiots,  found  no  less  than  one-half  of  them  to  be  the  last-born 
of  large  families.    Again,  these  children  occur  as  the  offspring 


DISEASES    OF   THE    THYMUS.  137 

of  aged  couples,  or  where  a  marked  disparity  in  age  exists 
between  the  parents.  To  use  a  homely  comparison,  the  fac- 
tory being  worn  out  in  toto  or  in  part,  the  product  is  below  par. 
Sajous,  Sr.,1'^8  has  made  the  suggestion  that  the  peculiar  Mon- 
golian facies  of  these  children  may  not  be  due  to  mere  hazard, 
but  may  reproduce,  to  some  extent,  effects  resulting  in  the 
Mongolian  branch  of  tbe  human  family  from  subsistence 
through  many  generations  on  an  "unbalanced"  diet.  A  diet 
consisting  too  exclusively  of  overmilled  rice  is  deficient  in 
phosphorus-containing-  compounds  or  vitamines,  and  on  this 
account,  underdevelopment  of  the  tissues  in  which  phosphorus 
containing  compounds  are  prominent,  viz.,  the  osseous  and 
cerebrospinal  systems,  may  logically  be  expected.  Common 
to  the  Eastern  Asiatic  races  and  the  Mongolian  idiot  are  slant- 
ing- eyes,  narrow  palpebral  fissures,  marked  epicanthus,  high 
cheek-bones,  a  yellowish  and  doughy  skin,  straight  hair,  a 
squatty  nose,  and,  lastly,  low  resisting-power  to  infectious  dis- 
eases, especially  in  the  rice-fed  "coolies."  These  features  are 
less  constant  in  the  upper  classes  of  Asiatics  than  the  lower, 
presumably  owing  to  the  greater  variety  of  food  ingested 
by  the  former,  which  obviates  the  deficiency  of  phosphorus 
intake. 

The  pathology  of  the  nerv^ous  system  in  Mongolian  idiocy 
shows  merely  an  imperfect  cellular  and  general  development 
of  the  brain,  without  any  definite  organic  lesion.  To  this  are 
added  certain  nutritional  lesions  in  the  osseous  system,  already 
referred  to.  As  regards  the  thymus  itself,  percussion  and 
radiography  indicate  absence  or  atrophy  of  this  organ  in  some 
and  hypertrophy  in  other  cases,  the  latter  condition  probably 
representing  an  effort  at  compensation  in  a  partly  diseased 
gland,  as  in  compensatory  hyperplasia  of  the  thyroid  in  hypo- 
thyroid goiter. 

Treatment.  On  the  whole,  the  results  of  treatment  in  Mon- 
golian idiocy  have  not  been  encouraging.  Probably  more 
could  be  done  for  these  cases,  however,  than  has  hitherto  been 
accomplished  were  the  physician  to  be  constantly  on  the 
watch  for  it  where  the  underlying-  conditions  exist,  viz.,  aged 
parents,  marked  discrepancy  in  age  of  parents,  markedly  pro- 
lific parents,  strong  emotion  or  affliction  in  the  mother,  syphilis, 
or  alcoholism.     Unusual  quiet  in  a  baby,  with  loose  joints  and 


138  DISEASES    OF   THE   DCCTLESS    GLANDS. 

persistent  helplessness,  is  also  a  suggestive  condition  which 
should  lead  to  careful  scrutiny  for  facial  characteristics  of 
]\Iongolism.  Treatment  through  the  nursing  mother  may  then 
be  instituted,  dried  thymus  gland,  0.3  gram  (5  gr.),  and  dried 
thyroid  and  pituitar}^  gland,  0.06  gram  (1  gr.)  of  each,  being 
given  three  times  daily  during  meals,  and  an  ample,  varied 
diet  prescribed.  AMiere  maternal  or  wet-nursing  cannot  be 
carried  out,  direct  nursing  using  goat's  milk  in  some  such  way 
as  is  employed  in  Italy,  Eg}-pt,  and  certain  other  countries,  is 
appropriate,  or,  if  cow's  milk  must  be  used,  it  should  be  fresh 
from  the  udder,  being  directly  pumped  into  the  nursing  bottle 
before  feeding. 

Treatment  of  the  older  Mongolian  child  consists  in  in- 
suring good  nourishment  and  countn,-  air,  as  well  as  in  giving 
organic  remedies.  The  doses  already  mentioned  for  the 
mother  are  appropriate  for  a  child  of  five  years,  but  the  dose 
of  dried  thymus  may  with  advantage  be  gradually  increased, 
up  to  1  gram  (15  gr.)  three  times  a  day.  The  dried  th3'roid 
and  pituitar}'  may  likewise  be  increased  if  stigmata  of  disease 
of  the  corresponding  gland  are  noticeable.  Iron  and  syrup  of 
hypophosphites  may  be  of  serv'ice  as  adjunct  remedies.  AVhere 
the  tonsils  are  enlarged  or  adenoid  tissue  present,  removal  is 
indicated. 

The  mental  condition  may  be  further  improved  by  per- 
sistent, systematic  education,  in  the  accomplishment  of  which 
the  patient  will,  as  a  rule,  readily  co-operate. 

The  Thymus  in  Backward  Children.  Apart  from  actual 
idiocy,  there  are  many  instances  of  relatively  slight  impairment 
of  the  mental  powers  in  which  the  ductless  glands  appear  to 
play  at  least  a  partial  role.  The  importance  of  the  subject  is 
shown  in  the  observation,  in  the  course  of  investigations  con- 
ducted by  the  Russell  Sage  Foundation  in  thirty-one  American 
cities,  that  over  20  per  cent,  of  all  school  children  belong  in 
the  "retarded"  class.  In  these  children  an  actual  mental  de- 
fect is  not  considered  to  exist,  but  the  development  of  the  mind 
is  hindered  by  unfavorable  environmental,  dietetic,  or  other  fac- 
tors. Enlarged  tonsils  or  adenoids,  errors  of  refraction,  insuffi- 
cient food,  absence  of  eftort  on  the  part  of  the  parents  to  extend 
the  vocabulary  and  develop  understanding,  removal  of  the 
stimulus  attending  association  with  other  children,  etc.,  are  all 


DISEASES   OF   THE   THYMUS.  139 

prejudicial  influences  which  must  be  overcome  before  organo- 
therapy can  be  expected  to  g-ive  results.  Anemia,  tuberculosis, 
or  inherited  syphilis  must,  where  present,  be  overcome  in  so 
far  as  is  possible. 

The  stigmata  of  deficiency  of  one  or  more  of  the  ductless 
glands,  in  particular  the  .thyroid,  pituitary,  adrenals,  or  thy- 
mus, must  then  be  carefully  sought  and  organic  remedies  ad- 
ministered according  to  the  findings. 

Where  the  thymus  is  deficient,  which  is  often  the  case  when 
larval  myxedema  is  present,  any  existing  mental  torpor — 
illustrated  in  a  tendency  to  answer  questions  slowly  and  with 
hesitation — is  ipso  facto  increased,  and  the  child's  osseous  sys- 
tem will  be  likely  to  show  deformities  suggesting  rickets,  to- 
gether with  the  looseness  of  the  ligaments  already  referred  to 
under  Mongolian  idiocy.  Sometimes  skin  disorders,  especially 
a  tendency  to  warts  and  eczema,  coexist.  In  cases  thus  ex- 
hibiting hypothymic  stigmata,  dried  thymus  gland  0.3  gram 
(5  gr.),  gradually  increased  to  0.6  gram  (10  gr.),  and  0.03 
gram  {^A  gr.)  of  dried  thyroids,  taken  in  the  course  of  each 
meal,  together  with  0.12  gram  (2  gr.)  of  calcium  lactate  after 
meals,  will  usually  afford  marked  improvement.  In  some 
cases  the  general  health  and  mental  condition  improve  in  a 
parallel  fashion ;  in  others  the  mental  deficiency  persists  even 
though  the  general  health  is  greatly  improved. 

In  all  these  cases  of  retarded  mental  development,  a  neces- 
sary feature  in  the  treatment  is  carefully  to  adjust  the  work 
required  of  the  child  to  his  actual  mental  capacity  at  the  time. 
To  estimate  accurately  the  degree  of  backwardness  in  a  given 
case,  the  Binet-Simon  method  or  one  of  its  modifications  is 
most  appropriate.  Special  classes  for  backward  children 
should  be  available  in  all  communities.  To  such  classes  the 
children  grouped  according  to  the  Binet-Simon  test  should  be 
referred  for  the  instruction  appropriate  to  each.  Aided  and 
encouraged,  but  not  goaded,  by  its  teachers,  the  backw^ard 
child  will  thus  often  become  an  object  of  surprise  in  the 
rapidity  of  the  progress  shown.  If  driven,  on  the  other  hand, 
beyond  the  working  powers  of  its  brain,  it  tends  soon  to  be- 
come discouraged,  unwilling,  stubborn,  and  irritable,  and  later 
not  infrequently  to  drift  toward  criminality,  and  find  its  way 
to  a  reformatory  or  prison. 


140  DISEASES    OF   THE   DUCTLESS    GLANDS. 

HYPERPLASIA  OF  THE  THYMUS. 

Abnormal  size  of  the  th^-mus  may  be  a  result  either  of 
retarded  involution,  the  gland  remaining  distinctly  larger  than 
the  a\'erage  size  indicated  by  the  age  of  the  patient,  or  of  an 
actual  hyperplasia,  the  organ  growing  to  a  larger  size  than 
normal.  Enlargement  of  the  thymus  has  repeatedly  been  ob- 
served to  follow  removal  of  both  testes,  and  is  also  an  acknowl- 
edged feature  of  many  cases  of  exophthalmic  goiter,  the  thy- 
mus often  taking  part,  indeed,  in  the  pathogenesis  of  the  lat- 
ter. Apart  from  these  conditions,  thymus  enlargement  is 
chiefly  of  clinical  interest  in  relation  to  three  forms  of  disturb- 
ances, viz.,  status  thymico  lymphaticus  or  status  lymphaticus ; 
thymic  asthma,  manifested  as  a  more  or  less  chronic  dyspnea 
or  in  paroxysms  of  stridulous  breathing,  and  thirdh",  th^-mic 
death,  the  sudden  exitus  of  apparently  health3r  subjects,  usu- 
ally infants,  in  the  absence  of  pre-existing  signs  of  compression 
of  the  trachea. 

Status  lymphaticus  was  first  emphasized  b}'  Paltauf  in  1889 
as  a  condition  characterized  by  hypertrophy  of  the  entire 
lymphatic  system,  including  the  thymus,  the  cervical  nodes, 
and  the  lymphatic  tissues  of  the  axilla,  mesentery,  tonsils,  and 
spleen.  To  this  syndrome  were  later  added  by  Bartels  the 
presence  of  a  small  heart,  a  narrow  aorta,  a  large  brain,  de- 
generation of  the  tln-roid,  a  small  vagina  and  infantile  uterus, 
and  a  general  lowering  of  the  resisting  power  of  the  organism 
to  infection.  The  thymic  hyperplasia  in  these  cases  may  be 
general — a  form  found,  according  to  George  Dock,i59  prob- 
ably only  in  infants — but  usually  is  limited  to  the  medulla  of 
the  thymus,  the  cells  in  this  section  of  the  organ  being  in- 
creased in  number,  while  the  cortex  may  be  actually  hypo- 
plastic. As  was  recognized  from  the  first  by  Paltauf,  status 
lymphaticus  predisposes  to  sudden  death  from  causes  which 
ordinaril}'  would  exert  little  or  no  harmful  effect. 

Direct  diagnosis  of  the  thymic  enlargement  is  often  not  an 
easy  task.  Such  obvious  indications  as  a  swelling  above  the 
manubrium  sterni,  prominence  of  the  manubrium,  and  a  tumor 
rising  in  the  jugular  fossa  in  inspiration  or  in  crying,  as 
Docki^o  has  pointed  out,  are  rarelv  present,  the  thymus  often 
lying  deeply  in  the  thorax.     The  bulk  of  the  enlarged  gland 


DISEASES    OF   THE   THYMUS.  141 

lies,  as  a  rule,  behind  the  upper  part  of  the  sternum,  extending-, 
however,  more  to  the  left  of  the  midline  than  to  the  right. 
Occasionally  the  organ  can  thus  be  mapped  out  by  gentle  per- 
cussion, the  area  occupied  by  it  forming  usually  a  triangle, 
with  its  base  at  the  level  of  the  sternoclavicular  articulation, 
and  its  blunt  apex  lower  down,  above  the  level  of  the  third 
rib.  If  the  dullness  extends  laterally  over  1  centimeter  (0.39  in.) 
beyond  the  margin  of  the  sternum,  morbid  enlargement  of  the 
thymus  is  indicated.  According  to  Jacobi,  the  dull  area  moves 
upward  when  the  head  is  thrown  far  back.  Among  other  in- 
dications of  enlarged  thymus,  special  stress  has  been  laid  upon 
hyperplasia  of  the  lymphatic  tissues  at  the  root  of  the  tongue. 
Often  a  thymic  enlargement  is  discernible  by  examination  with 
the  A'-rays ;  in  some  instances,  however,  such  examination  has 
proven  misleading,  no  thymic  swelling  being  found  upon  oper- 
ating, in  spite  of  positive  .v-ray  indications.  Lange,  of  Cin- 
cinnati, has  worked  out  a  careful  technic  of  .f-ray  diagnosis, 
which  is  described  by  A.  Friedlander.i^i 

That  an  abnormally  large  thymus  may  at  times  cause  pres- 
sure symptoms  is  doubted  by  no  one,  but  there  is  still  con- 
siderable difference  of  opinion  as  to  the  frequency  with  which 
such  s3^mptom-causing  enlargement  exists.  The  symptoms 
themselves,  which  develop  suddenly  or  gradually,  usually  dur- 
ing the  first  year  of  life,  and  at  times  are  witnessed  imme- 
diately after  birth,  are  in  general  manifestations  of  tracheal 
stenosis.  The  dyspnea  may  be  constant  or  paroxysmal,  and 
is  usually  made  worse  by  crying,  fits  of  anger,  rapid  backward 
bending  of  the  head,  or  some  acute  infection,  diphtheria  in  par- 
ticular. Stress  has  been  laid  by  various  authors  on  a  pre- 
sumed special  susceptibility  of  the  thymus  to  rapid  conges- 
tion, due  to  its  arterial  supply  being  more  abundant  than  its 
efferent  venous  channels.  Cyanosis  is  another  typical  symp- 
tom, which  may  be  the  result,  however,  not  only  of  pressure 
upon  the  air  passages,  but  also  of  compression  of  the  vagus 
nerves,  the  great  vessels,  and  the  heart  itself.  The  pulse-rate 
may  be  slowed,  doubtless  likewise  through  pressure  on  the 
vagus  nerves.  Voice  abnormalities  are  ascribed  either  to  tra- 
cheal pressure  or  to  compression  of  the  recurrent  lar3mgeal 
nerve,  and  range  from  slight  temporary  hoarseness  to  aphonia. 
Inspiratory  retraction  of  the  supra-  and  infra-  sternal  regions, 


142  DISEASES    OF    THE    DUCTLESS    GLAXDS. 

in  the  absence  of  hoarseness,  has,  however,  been  considered  a 
suggestive  manifestation.  Pressure  on  pulmonary  vessels  may 
actively  promote  congestion  of  the  bronchial  vascular  distribu- 
tion, and  lead  eventually  to  a  capillar}-  bronchitis,  which  in 
turn  may  pass  into  bronchopneumonia.  In  some  cases,  it  is 
asserted,  there  is  also  pressure  upon  the  esophagus,  which  may 
be  such  as  completely  to  prevent  swallowing. 

In  the  "status  thymicolymphaticus"  the  symptoms  just 
mentioned  are  apt,  according  to  F.  H.  Fals,^^-  to  be  less 
marked,  the  predominating  features  being  the  general  enlarge- 
ment of  lymphatic  structures,  a  pasty  skin,  adiposity,  and  asso- 
ciated changes  in  the  chromaffin  system.  In  these  cases  espe- 
cially is  sudden  death  believed  to  occur.  Opinions  are  still 
markedty  at  variance,  however,  as  to  the  frequency,  or  even  the 
possibility,  of  true  "thymus  death."  According  to  Hammar,!^^ 
investigation  in  16  personal  cases  revealed  no  abnormalities  of 
the  thymus  which  would  account  for  sudden  death ;  this  ob- 
server is  disposed  to  ascribe  the  fatal  ending  to  other  ductless 
glands.  Xordmanni64  ascribes  thymic  asthma  not  to  mechan- 
ical pressure  by,  but  to  hyperfunction  of,  the  thymus.  Again, 
according  to  J.  Grossman. ^^^  autopsies  after  "thymus  death" 
have  disclosed  local  anemia,  flattening,  partial  obliteration, 
and  atrophy  of  the  tracheal  wall,  which  have  been  proven  due 
to  compression  of  the  trachea  by  an  enlarged  thymus.  Fatal 
cases  showing  an  apparently  normal  thymus  are  explained  as 
having  occurred  through  an  edema  or  congestion  of  the  gland, 
which  disappeared  after  death.  Schoeppleri^^  asserts  that  in 
a  case  of  sudden  cyanosis  and  death  in  a  child  a  year  and  a  half 
old  the  thymus  was  found  to  weigh  85  grams,  and  the  trachea 
was  so  compressed  by  it  that  a  sound  could  be  passed  through 
only  at  the  sides  in  the  narrowed  portion. 

Jacobi  is  quoted  by  Falls^^T  iq  the  effect  that  pressure  from 
acute  congestion  of  the  thymus  on  the  trachea,  great  vessels, 
and  nerves  explains  a  certain  number  of  cases  of  thymic  death, 
but  not  all.  Garrod^^s  found  there  was  evidence  that  not  a 
few  cases  of  supposed  thymic  death  had  actually  been  due  to 
suffocative  bronchopneumonia.  Grififithi69  has  expressed  him- 
self as  believing  that  such  deaths  are  cardiac  deaths,  that  there 
is  no  anatomic  proof  of  sudden  thymus  congestion,  and  that 
the  most  generally  accepted  theor\'  accounts  for  the  condition 


DISEASES    OF    THE   THYMUS.  143 

as  a  neurosis,  perhaps  toxic  in  origin,  sudden  cardiac  arrest 
occurring  for  some  unknown  cause  which  varies  witli  the  case. 
Gismondii'^o  lays  stress  on  direct  compression  by  the  thymus, 
not  only  of  the  trachea,  but  of  the  veins  from  the  brain  and 
arm,  thus  impeding-  indirectly  the  circulation  in  the  veins  of 
the  already  enlarged  thymus  itself,  and  setting  up  a  vicious 
circle.  Simultaneously  the  bronchial  mucosa  is  congested, 
compression  of  the  pulmonary  veins  interferes  with  blood 
aeration ;  through  the  combined  action  of  these  unfavorable 
conditions  dang-erous  asphyxia  may  suddenly  develop. 

TREATMENT. 

Not  infrequently  spontaneous  recovery  from  thymic  asthma 
takes  place,  even  where  dyspneic  seizures  have  recurred  for 
several  years  (Rehn).  Measures  to  accelerate  involution  of  the 
gland  are,  however,  available,  and  likewise  precautions  appro- 
priate for  warding  off  attacks  of  dyspnea  or  actual  asphyxia. 
In  young  infants  without  especially  alarming  symptoms,  Gis- 
mondii'^'i  found  painting  with  iodin  useful  to  hasten  thymic 
retrogression.  Particularly  to  be  avoided  for  the  prevention  of 
seizures  are  excitement  of  the  child,  crying  or  screaming,  run- 
ning or  jumping,  swimming,  baths  at  extreme  temperatures, 
and  the  throwing  of  the  head  far  backward.  The  child  should 
live  out  of  doors  in  an  even  climate,  under  hygienic  conditions, 
and  with  a  well  regulated  diet. 

X-ray  treatment  of  the  enlarged  thymus  has  been  applied 
by  a  number  of  observers  with  successful  results.  Although 
some  authors  have  held  that  such  treatment  should  be  re- 
stricted to  older  children  and  adults,  more  recent  observations 
seem  to  have  shown  that  it  is  attended  with  but  little  danger, 
even  in  young  children.  Friedlanderi'^2  deems  the  .i"-ray  treat- 
ment remarkably  efficacious.  In  the  average  case,  improve- 
ment of  symptoms  was  noted  within  twenty-four  to  forty- 
eight  hours.  The  Lange  technic  was  used,  a  Coolidge  tube  and 
9j/  inch  spark  being  emplo3^ed,  with  the  rays  filtered  through 
4  millimeters  of  aluminum,  and  a  piece  of  thick  leather.  The 
target  skin  distance  was  9  inches,  and  the  routine  exposure, 
25  milliarapereminutes.  In  mild  cases  a  single  dose  over  the 
anterior  aspect  of  the  chest  sufficed,  while  in  more  urgent 
cases  50  milliampereminutes  were  administered,  25  anteriorly 


144  DISEASES    OF   THE   DUCTLESS    GLANDS. 

and  25  posteriorly.  The  interval  between  treatments  was 
usually  one  week  unless  urgent  symptoms  indicated  more  fre- 
quent applications.  Stress  is  laid  on  sufficiency  of  dosage,  fail- 
ure to  administer  full  doses  and  repeat  them  promptly  having 
in  very  urgent  cases  led  to  fatalities  under  .r-ray  treatment. 
In  a  series  of  over  100  cases  referred  to  by  Friedlander  there 
were  4  deaths. 

According  to  P.  H.  Cook,i~3  cases  have  been  recorded  in 
which  symptoms  were  relieved  in  three  and  a  half  hours  after 
application  of  the  .r-rays.  The  same  writer  quotes  Lange  as 
urging  that  recurrences  due  to  regeneration  of  the  gland  should 
be  kept  under  observation  and  controlled  by  further  treatment. 
Lange  advocates  .r-ray  therapy  as  a  precautionary^  measure  in 
children  of  the  "lymphatic  type,"  to  enable  them  to  withstand 
intercurrent  disease  or  anesthesia  which  would  otherAvise 
prove  fatal.  Gismondii"-*  warns  against  a  too  A'iolent  .r-ray 
treatment,  reporting  a  case  in  which  a  mild  tendency  to  rickets 
was  whipped  up  into  a  severe  grade  of  the  disease  by  a  series 
of  excessive  exposures.  He  would  set  the  limit  of  a  single 
dose  at  5  or  6  H  units,  an  aluminum  filter  being  used. 

Medication  with  dried  thymus  gland  has  been  attempted  in 
these  cases,  but  without  efifect  on  the  enlarged  organ,  as  might 
have  been  expected.  Good  results  from  daily  administration 
of  adrenalin  in  small  doses  have,  however,  been  reported  by 
Franchetti  and  Pende.  The  latter  observ^er  prefers,  moreover, 
a  mixture  of  adrenalin  with  pituitan^  extract,  ascribing  to  this 
combination  a  definite  inhibitory  property  in  relation  to  the 
enlarged  thymus. 

Surgical  removal  of  a  portion  of  the  thymus  has  been  car- 
ried out  successfully  in  a  relatively  large  number  of  cases,  but 
the  procedure  is  attended  with  a  higher  mortalitv  than  .I'-ray 
treatment.  C.  A.  Parker,i~^  analyzing  50  cases  of  thymectomy 
at  all  ages,  noted  17  deaths,  but  reported  a  successful  case  of 
his  own,  and  recommended  surgical  inter^'ention  when  the  thy- 
mus causes  symptoms.  Total  thymectomy  appears  to  have 
been  found  highly  unsatisfactorA%  metabolic  disturbances  and 
rachitic  phenomena  following,  at  least  in  some  instances.  The 
usual  procedure  is  therefore  a  partial  intracapsular  thymectomy. 
This  ma}'  be  performed  b}'  effecting  an  entrance  into  the 
thorax  above  the  suprasternal  notch.     General  or  local  anes- 


DISEASES    OF    THE    PITUITARY    BODY.  145 

thesia  may  be  used,  according  to  indications,  the  fact  being- 
borne  in  mind  that  in  status  lymphaticus  with  enlarged  thy- 
mus death  during  general  narcosis  has  been  not  infrequent. 
Fallsi"*^  deems  it  doubtful  whether  thymectomy  should  be 
undertaken  except  where  there  is  severe  tracheal  stenosis. 


DISEASES  OF  THE  PITUITARY  BODY. 

This  organ  consists  of  three  distinct  parts,  viz.,  the  an- 
terior or  "glandular"  lobe,  constituting-  approximately  three- 
fourths  of  the  whole ;  the  pars  intermedia,  a  narrow,  whitish 
layer  situated  behind  the  anterior  lobe  and  constituting  a  lin- 
ing around  the  posterior  portion ;  and  the  posterior  lobe  itself, 
rounded  in  shape  and  partly  enclosed  by  the  larger  anterior 
lobe.  Histologically,  the  anterior  pituitary  exhibits  two  main 
types  of  epithelial  cells,  the  chromophiles,  which  have  a 
marked  affinity  for  either  basic  or  acid  stains  and  embody 
granules  apparently  of  secretory  origin,  and  the  chromophobes, 
which  do  not  stain  so  readil)^  and  contain  no  clearly  manifest 
granulations.  These  cells  are  disposed  in  solid  columns,  and 
between  the  latter  course  broad,  thin-walled  blood  channels. 
The  pars  intermedia  consists  of  several  layers  of  finely  granu- 
lar cells,  which  produce  a  colloid  material  believed  by  some  to 
contain  the  active  principle  or  principles  In  pituitary  extract. 

The  posterior  or  neural  lobe,  is  coated  posteriorly,  accord- 
ing to  Berkley,!'^^  by  a  layer  of  gray  matter  composed  of 
ependymal  cells  three  or  four  deep.  The  greater  part  of  this 
lobe,  however,  is  characterized  by  a  rather  dense  aggregation 
of  nerve-cells,  more  or  less  divided  into  subsidiary  groups  by 
connective  tissue  partitions  carrying  blood-vessels.  These 
nerve-cells  are  of  various  types,  some  being  different  in  struc- 
ture from  any  other  nerve-cells  in  the  central  or  peripheral 
nervous  systems.  Berkley  considers  it  doubtful  whether  any 
of  the  fibers  from  these  cells  pass  out  of  the  posterior  lobe 
into  the  infundibulum  or  stalk  of  the  pituitary,  which  connects 
the  latter  with  the  base  of  the  brain  proper.  Ramon  y  Cajal, 
Andriezen,  Gentes,  and  others,  however,  were  able  to  satisfy 
themselves  that  nerve  fibers  do  pass  from  the  posterior  lobe 
and  the  pars  intermedia  to  the  tuber  cinereum  and  even  be- 
yond.    Another  feature  of  interest  with  regard  to  the  hypo- 

10 


146  DISEASES    OF   THE    DUCTLESS    GLANDS. 

physis  is  the  differing  embryological  derivation  of  its  several 
sections,  the  anterior  lobe  and  pars  intermedia  developing 
from  the  ectodermal  epithelium  of  the  primitive  oral  cavity, 
while  the  posterior  lobe  is  derived  from  the  embryonic  brain 
or,  more  particularly,  from  the  infundibulum,  the  latter  at- 
tached to  the  floor  of  the  third  ventricle. 

The  composite  make-up  of  the  hypophysis  introduces  into 
the  study  of  its  functions  and  morbid  conditions  a  complexity 
which  clearly  necessitates  a  brief  review  of  various  outstanding 
experimental  and  other  observations  if  the  pathogenesis  and 
treatment  of  clinical  pituitary  disorders  are  to  be  understood. 
Experimental  investigators  of  the  pituitary  have  in  late  years 
come  into  agreement  to  the  effect  that  this  organ  is  essential  to 
life,  its  complete  removal  causing  death.  Removal  of  the 
posterior  lobe  alone  causes  no  symptoms,  but  removal  of  a 
large  portion  of  the  anterior  lobe  is  fatal.  .  Removal  of  a 
smaller  portion  of  this  lobe  in  dogs  has  been  shown  by  Crowe, 
Gushing,  and  liomans^'^  to  induce  a  characteristic  state  of 
adiposity  coupled  with  sexual  infantilism  in  young  animals 
and  secondan^  hypoplasia  of  the  generative  organs  in  adults. 
Polyuria,  glycosuria,  h^'potrichosis,  edema  of  the  skin,  sub- 
normal temperature,  and  mental  changes  were  also  commonly 
noticed.  Aschner,!"^  in  similar  experiments  in  puppies,  ob- 
served in  conjunction  with  these  effects  a  marked  retardation 
in  body  growth,  reduced  general  activity,  persistence  of  the 
puppy  type  of  hair  and  of  the  milk  teeth,  a  thick  and  inelastic 
skin,  failure  of  the  epiphyses  to  close,  a  hypoplastic  state  of 
the  bony  skeleton,  fatty  infiltration  of  the  liver,  enlargement 
of  the  colloid  alveoli  in  the  thyroid  gland,  unusual  thickness 
of  the  adrenal  cortex,  and  a  persistent  thymus.  These  changes 
are  ascribed  mainty  to  the  anterior  lobe.  Confirmation  of  the 
especially  prominent  influence  of  this  lobe  on  the  essential 
organs  of  sex  (gonads)  has  been  afforded  by  the  feeding  of 
extracts  of  the  anterior  lobe  in  animals.  Goetschi^o  gave  such 
extracts  to  young  rats,  and  observed  premature  maturity  and 
functional  activity  of  the  ovaries,  tubes,  and  uterine  cornua, 
more  marked  than  follows  feeding  of  corpus  luteum.  A  pair 
of  rats  fed  anterior  pituitar^^  bred  earlier  and  oftener  than  con- 
trols, the  effects  lasting  throughout  the  adult  life  of  these 
animals. 


DISEASES    OF    THE    PITUITARY    BODY.  147 

The  posterior  lobe  of  the  pituitary,  although  experimentally 
not  essential  to  life  as  is  the  anterior  lobe,  has  been  shown  by 
HowelU^i  to  be  the  chief  repository  of  the  blood-pressure- 
raising  principle  of  this  organ.  The  anterior  lobe  contains 
none  of  this  principle,  while  the  pars  intermedia,  it  is  said, 
contains  it  in  less  amount  than  the  posterior  lobe.  Apparently 
embodied  in  the  colloid  secretion  of  the  pars  intermedia,  the 
active  principle  has  been  supposed  by  Herringi'^2  a^^^i  others 
to  pass  through  the  posterior  lobe  and  thence  into  the  third 
ventricle  of  the  brain.  More  recently,  however,  Blair  Belli'^-^ 
has  asserted  that  there  is  not  the  slightest  evidence  to  the 
effect  that,  even  if  secretion  from  the  neural  lobe  does  pass 
into  the  cerebrospinal  fluid,  this  is  an  essential,  beneficial,  or 
even  the  normal  method  by  which  the  internal  secretion  is 
taken  by  the  animal  economy.  The  blood-stream,  on  the  other 
hand,  is  by  this  investigator  considered  the  real  channel  for 
distribution  of  the  pituitary  hormone.  Again,  according  to 
Goetsch,iS4  "-the  cells  of  the  anterior  lobe  without  doubt  dis- 
charge their  secretion  directly  into  the  large  blood  and  lymph 
sinuses  which  are  so  numerous  here  and  with  which  the  cells 
are  in  such  intimate  contact."  According  to  these  conceptions, 
as  the  reader  will  have  noticed,  the  pituitary  would  have  not 
one,  but  two  secretions. 

In  contrast  with  the  mental,  cutaneous,  osseous,  dental, 
thyroid,  and  other  disturbances  ascribed  to  the  interference 
with  the  anterior  lobe  in  experimental  hypophysectomy,  the 
disturbances  of  carbohydrate  metabolism  attending  experimen- 
tal manipulations  of  the  pituitary  have  been  attributed  to  in- 
volvement of  the  infundibulum  and  posterior  lobe.  Thus, 
Goetsch,  Gushing,  and  Jacobsoni^^  found  that  various  opera- 
tive manipulations  of  the  stalk  of  the  pituitary  and  of  the 
posterior  lobe  itself  caused  a  temporary  hyperglycemia,  wath 
associated  diminution  of  the  assimilation  limit  for  ingested  car- 
bohydrates and  frequently  a  transient  glycosuria.  Upon  pro- 
ducing a  permanent  insufficiency  of  posterior  lobe  secretion, 
however,  these  phenomena  were  followed  by  an  abnormal  and 
lasting  rise  in  sugar  tolerance,  which  could  be  removed  by 
intravenous  or  subcutaneous  injection  of  posterior  lobe  ex- 
tract. In  the  intact  animal,  indeed,  such  injections  reduce 
even  the  normal  sugar  tolerance,  and  in  sufficient  dosage  may 


148  DISEASES    OF    THE    DUCTLESS    GLANDS. 

cause  actual  glycosuria.  According  to  Goetsch/so  ^^g  adipos- 
ity following  hypophysectomy  is  probably  also  a  result  of 
deficiency  of  the  posterior  lobe  secretion,  rather  than  due  to 
the  interference  with  the  anterior  lobe. 

As  regards  excessive  posterior  lobe  secretion,  the  same  in- 
vestigator concluded  from  feeding  experiments  with  this  lobe 
that,  in  contrast  to  anterior  lobe  feeding,  it  has  an  undoubted 
retarding  influence  on  the  development  of  the  sex  glands,  as 
shown  in  rats  by  a  relatively  incomplete  growth  of  the  testes 
after  eight  and  one-half  months  of  posterior  lobe  feeding. 
From  the  facts  that  the  genitals  remain  normal  and  young 
animals  continue  to  develop  after  ablation  of  this  lobe,  Blair 
Belli^"  is  even  disposed  to  assert  that  the  secretion  of  the 
posterior  lobe  is  neither  beneficial  nor  essential  to  life. 

Sajous,  Sr.,188  mindful  of  the  prominent  nervous  com- 
ponents of  the  posterior  lobe,  and  maintaining  the  view  of  a 
definite,  direct  connection  of  this  lobe  through  the  infundi- 
bulum  with  overlying  nerve  tissues,  considers  the  posterior 
pituitary  an  important  nerve  center,  capable  of  influencing  the 
functional  activity  of  all  organs  through  the  intermediary  of 
subsidiary  centers  in  the  medulla  and  spinal  cord.  Being  but 
a  co-ordinating  center,  it  is  not  necessar}'  to  life.  He  also 
considers  it  as  the  sensor}'  organ  upon  which  shocks  and  trau- 
matisms in  general  react  most  powerfully — a  circumstance 
illustrated  in  the  pathogenesis  of  acromegaly,  fully  20  per  cent, 
of  the  cases  of  which  arise  through  some  form  of  accident, 
physical  or  mental,  frequently  a  fall  upon  the  head.  In  regard 
to  the  pars  intermedia,  Sajous,  Sr.,  assimilates  the  nerve-cells 
found  in  this  portion  of  the  organ  by  Gentes,!^^  and  extending 
by  their  axons  through  the  posterior  lobe  to  the  base  of  the 
brain,  to  the  osphradium  of  sea-dw^elling  invertebrates — a  sen- 
sory organ  believed  by  naturalists  to  represent  in  ancestral 
form  the  pituitarv  body  of  vertebrates  and  to  have  the 
function  of  testing  the  quality  of  the  water  passing  over  the 
respiratory  organ  of  these  animals.  The  pars  intermedia,  as 
the  test  organ  of  the  blood — the  latter  a  homologue  of  the  sea 
water  in  which  the  tissues  of  the  invertebrates  are  bathed — is 
thus  conceived  of  as  keeping  watch  over  the  purity  of  the 
blood,  and  in  the  presence  of  circulating  toxic  substances  as 
awakening   a  febrile   reaction   for  their  destruction   through 


DISEASES   OF   THE    PITUITARY    BODY.  149 

nervous  excitation  of  the  anterior  portion  of  the  floor  of  the 
third  ventricle,  immediately  above  the  pituitary,  in  which  a 
thermogenic  center  was  found  by  Ott.  This  theory  attributes 
the  metabolic  phenomena  witnessed  in  disorders  of  the  pituit- 
ary, such  as  acromegaly,  adipositas  cerebralis,  etc.,  to  the  thy- 
roid, adrenals,  etc.,  with  which  the  pituitary  is  functionally 
connected  by  nerve  paths,  the  posterior  lobe  not  being,  accord- 
ing to  Sajous,  Sr.,  Biedl  and  others,  a  secreting  organ.  Recent 
observations  too  comprehensive  to  be  treated  in  the  present 
connection,  tend  increasingly  to  sustain  this  view. 

The  acute  pharmacologic  effects  of  extracts  of  the  posterior 
lobe  and  pars  intermedia  are  so  well  known  as  to  require  little 
discussion.  The  chief  circulatory  action  is  a  direct  constric- 
tion of  the  peripheral  blood-vessels,  causing  a  pronounced  rise 
in  blood-pressure,  more  prolonged  than  in  the  case  of  adrenalin. 
Concurrently  there  is  a  slowing  of  the  heart-rate,  commonly 
ascribed  to  a  depressor  substance  in  the  extract.  Other  char- 
acteristic actions  are  the  now  widely  utilized  oxytocic  action ; 
the  diuresis,  ascribed  mainly  to  renal  vasodilatation ;  the  ac- 
centuation of  peristalsis  in  the  intestine  and  of  the  bladder 
contractions,  and  the  galactag"og'ue  effect,  variously  ascribed 
to  specific  stimulation  of  the  secreting-  mammary  cells  and  to 
contraction  of  the  smooth  muscle  around  the  mammary  ducts. 

PITUITARY  OVERACTIVITY  (HYPER- 
PITUITARIA). 

Definite  grouping  of  pituitary  affections  into  those  char- 
acterized by  overactivity  and  those  with  functional  insuffi- 
ciency of  the  org'an  is  interfered  with  not  only  by  the  fact 
that  an  initial  overactivity  may  after'  a  time  pass  into  insuffi- 
ciency but  because  the  organ  is  composed  of  separate  lobes, 
which  may  be  independently  involved.  Again,  overactivity  of 
one  lobe  may,  by  enlargement  and  pressure,  cause  insufficiency 
of  the  other,  and  enlargement  of  the  organ  as  a  whole  may 
produce  "neighborhood  symptoms"  by  pressure  on  other  struc- 
tures in  the  vicinity  or  may  induce  the  general  manifestations 
of  increased  intracranial  pressure.  To  cases  exhibiting  a  com- 
bination of  some  symptoms  of  pituitary  overactivity  (hyper- 
pituitaria   or  hyperpituitarism)    with   others   of  pituitary   in- 


150  DISEASES    OF   THE   DUCTLESS'  GLANDS. 

sutticiencv  (^h}-popituitaria).  the  term  dyspituitaria  (dyspit- 
uitarism )  is  sometimes  applied.  Commonly,  the  symptoms  of 
overactivity  or  insufficiency  of  one  of  the  lobes  clearly  pre- 
dominate over  all  other  symptoms,  thus  indicating  the  part 
of  the  organ  chiefly  affected  and  the  nature  of  the  involvement. 

All  grades  of  pituitarv  overactivity  may  occur,  from  a  mild, 
evanescent  type  to  the  more  pronounced  and  lasting  form  re- 
sulting from  chronic  pituitan.'  disease.  An  increase  in  weight 
of  the  anterior  lobe  has  been  shown  to  occur  toward  the  close 
of  pregnancy,  the  enlargement  of  this  lobe  being  due  to  marked 
accumulation  in  it  of  special,  clear,  neutrophilic  "pregnancy 
cells,"  derived  from  the  normal  chromophobe  cells.  The  hy- 
perplasia is  exceptionally  such  as  to  induce  a  transient  bitem- 
poral hemianopsia  from  pressure  on  the  optic  chiasm,  together 
with  signs  of  pituitar}'  overfunction  such  as  thickening  of  cer- 
tain parts  of  the  face,  enlargement  of  the  hands  and  feet,  and 
glycosuria,  all  of  A^hich  as  a  rule  disappear  in  a  few  months 
after  delivery.  If,  however,  involution  of  the  pituitar\"  is  in- 
complete, a  species  of  strumous  degeneration  of  the  organ  may, 
after  repeated  pregnancies,  result,  eventually  inducing  symp- 
toms of  hypopituitaria. 

According  to  some.  SA-philis  is  a  frequent  cause  of  pituitary 
disturbance,  presumably  at  iirst  a  hyperpituitaria,  later  fol- 
lowed by  the  opposite  condition.  Harrower^^*^  believes  hered- 
itv  is  an  evident  factor  in  such  cases,  and  syphilis  in  parents 
and  grandparents  may  leave  "an  intangible  susceptibility"  to 
pituitary-  disturbance.  Either  glandular  hyperplasia  or  true 
tumor  formation  mav  be  responsible  for  the  more  pro- 
nounced forms  of  pituitar}-  overactivitA-.  mainly  exemplified  in 
acromegaly. 

In  classifying  conditions  of  pituitan.-  overactivity-  accord- 
ing to  the  lobe  chiefly  involved,  acromegaly  and  gigantism  are 
generally  given  as  manifestations  of  overactivit}-  of  the  ante- 
rior lobe.  To  overactivity  of  the  posterior  lobe  A.  D.  Dunn^^'i 
is  inclined  to  ascribe  diabetes  insipidus.  He  also  recognizes  a 
mixed  affection  marked  by  overactivity  of  the  anterior  lobe  and 
insufficienc}-  of  the  posterior,  the  result  being  acromegaly 
coupled  with  hypophysial  obesity.  Discussion  of  acromegaly 
and  gigantism  under  the  heading  pituitan,-  overactivity  is  ap- 
propriate because  in  the  initial  stages  of  these  affections  such 


DISEASES    OF   THE    PITUITARY    BODY.  151 

overactivity  is  believed  to  occur;  the  fact  is  to  l)e  remembered, 
however,  that  in  the  later  stages  of  these  conditions  manifesta- 
tions of  pituitary  insufficiency  are,  on  the  contrary,  likely  to 
exist. 

Acromegaly  and  Gigantism.  Tumors  of  the  Pituitary  Body. 
Acromegaly  or  Marie's  disease  is  attributed  to  pituitary  over- 
activity occurring  after  ossification  of  the  epiphyses.  Gigan- 
tism or  Launois's  disease,  on  the  contrary,  results  w^here  the 
hyperpituitaria  has  become  established  before  epiphyseal  ossi- 
fication. Tumors  of  the  pituitary  are  so  merged  symptomatic- 
ally  with  those  of  the  various  stages  of  acromegaly  as  to  im- 
pose the  necessity  of  considering-  them  under  the  same  heading. 

In  nearly  all  cases  of  acromegaly  in  which  examination  of 
the  pituitar}^  has  been  practicable,  before  or  after  death,  evi- 
dences of  a  hyperplasia  or  adenomatous  process  of  the  organ 
have  been  found.  Exceptions,  as  Cushing^^^  points  out,  have 
been  too  few  to  invalidate  the  pituitary  origin  of  this  disease, 
especially  when  it  is  recalled  that  the  osseous  changes  of  acro- 
megaly persist  to  the  end  of  life  even  where  a  pre-existing  hy- 
perplasia of  the  organ  has  undergone  complete  involution.  As 
regards  the  exact  nature  of  the  earlier  histological  changes  in 
acromegaly  some  degree  of  uncertainty  still  prevails,  oppor- 
tunities to  examine  the  organ  during  the  primary  stage  of 
overfunction  being  few.  Cushing,!^^  among  29  cases  of  pituit- 
ary disease,  found  23  instances  of  epithelial  growth  or  struma 
originating  from  the  pituitary  itself,  20  of  these  exhibiting  large 
pituitar)^  strumas  of  chromophobe  cells,  with  coexistent  symp- 
toms of  secondary  /^y/'opituitaria.  The  remaining  six  cases 
of  pituitary  disease  showed  extrapituitary  tumors  which  had 
caused  pituitary  symptoms  by  compressing  this  organ.  None 
of  these  extrapituitary  tumors,  however,  had  been  associated 
with  actual  acromegaly  except  in  one  instance ;  and  in  the  latter  a 
cerebellar  cyst  and  hyperplasia  of  the  anterior  lobe  were  found 
to  coexist.  Evidently,  therefore,  true  acromegaly  is  practically 
limited  to  cases  in  which  actual  hyperplastic  or  adenomatous 
changes  in  the  hypophysis  have  arisen,  and  is  not  likely  to 
occur  as  a  result  of  pressure  on  this  organ  by  a  tumor  arising 
in  other  tissues.  Gushing  points  out  that  the  so-called  round- 
celled  sarcomas  of  the  pituitary  are  actually  strumas  charac- 
terized by  the  presence  of  large  numbers  of  neutrophilic  or 


152 


DISEASES    OF    THE    DUCTLESS    GLAXDS. 


"chromophobe""  cells.  These  cells  correspond  in  particular 
to  the  secondary  hypopituitaric  stage  of  acromegaly,  the  cells 
characteristic  of  /n'/'^rpituitaria  being,  on  the  contran,',  con- 


Fig.  4. — Mold  of  the  upper  extremity  in  a  case  of 
acromegaly.     (P.  E.  Laiowis.) 


sidered   to   be   the   acidophile   or  eosinophile   elements   of  the 
pituitar}-. 

Of  the  symptoms  of  acromegaly  and  gigantism,  some  are 
to  be  ascribed  to  the  changes  in  the  pituitary  itself  and  the 
remainder  to  other  influences.  Among  the  manifestations  of 
the  primary  overfunction  of  the  hypophysis   are   classed  the 


DISEASES    OF    THE    PITUITARY    BODY.  I53 

skeletal  changes,  the  h}-pertrophic  modifications  in  the  skin 
and  its  glandular  appendages,  and  the  frequent  glycosuria, 
polyuria,  and  polydipsia.  As  to  the  mentality,  Gushing  notes  in 
hyperpituitaria  certain  temperamental  changes,  in  particular 
irritability,  distrust,  indecision,  coupled  with  an  inability  to 
concentrate  and  sleeplessness. 

In  the  second  stage  of  hypopituitaria,  the  bony  changes  per- 
sist practically  unmodified,  but  the  thickening  of  the  skin  and 
bogginess  of  the  subcutaneous  tissues  tend  slowly  to  disap- 
pear, and  there  occur  such  conditions  as  marked  asthenia, 
drowsiness,  hypothermia,  slowing  of  the  pulse-rate,  low  blood- 
pressure,  abnormal  sugar  tolerance,  and  a  tendency  to  obesity. 
Gushing  ascribes  all  these  phenomena  to  insufficiency  of  the 
posterior  lobe,  though  admitting  that  the  low  blood-pressure, 
asthenia,  and  pigmentation  noticed  in  a  number  of  his  cases 
suggest  an  added  secondary  inactivity  of  the  adrenals.  Sajous, 
Sr.ji^"*  had  previously  emphasized  this  fact,  and  considers  the 
manifestations  of  the  second,  asthenic  stage  of  acromegaly 
actually  due  to  hypoadrenia  and  hypothyroidia,  the  stimulat- 
ing impulses  to  the  adrenals  and  th^^roid  from  the  posterior 
pituitary,  which  acts  as  governing  center  of  these  organs 
through  nervous  connections,  being  abolished  when  pressure 
upon  or  destruction  of  the  posterior  lobe  abrogates  the  func- 
tional activity  of  the  latter. 

In  the  primary  erethic  or  sthenic  stage  of  acromegaly 
stress  is  likewise  laid  by  Sajous,  St.,  on  the  participation 
of  an  induced  hypcr^drema.  and  /?v/'^rthyroidia.  Support  is 
afi^orded  his  view  of  adrenal  participation  in  the  acromegalic 
syndrome  by  Gushing's  Gase  XXXII  (the  giant  Turner), 
whose  autopsy,  following  a  period  of  marked  "hypopituitaria" 
and  asthenia,  revealed  exceedingly  diminutive  adrenals,  with 
a  transverse  diameter  of  only  2  millimeters,  and  no  macro- 
scopical  trace  of  chromaffin  elements.  In  Gushing's  Gase  II, 
on  the  other  hand,  in  which  death  took  place  from  medullary 
failure  after  hypophyseal  decompression  for  a  recent  and  pro- 
gressive //3'/i^rpituitaria,  the  adrenals  were  found  large,  with 
their  medullas  apparenth'  hypertrophic. 

The  non-glandular  manifestations  of  acromegaly,  which 
occur  mainly  m  the  second  stage  of  the  disease,  include  head- 
ache, ascribed  by  Gushing  to  distention  of  the  capsule  of  the 


154  DISEASES    OF   THE    DLXTLESS    GLANDS. 

pituitary;  enlargement  and  deformation  of  the  sella  turcica; 
visual  impairment  due  to  pressure  by  the  growth  on  the  optic 
chiasm ;  distortions  of  the  fields  of  vision  and  oculomotor  dis- 
turbances ;  occasionally  anosmia,  trigeminal  neuralgia,  spas- 
ticity, uncinate  epileptic  seizures,  frontal  lobe  manifestations, 
epistaxis,  and  an  intermittent  discharge  6i  mucus  into  the 
pharynx.  Apart  from  signs  due  to  direct  pressure  on  neighbor- 
ing structures  by  the  growth,  the  customan,^  phenomena  of  a 
general  increase  in  intracranial  tension  may  also  exist. 

In  many  instances  the  pituitary  disturbance  reacts  upon  the 
sexual  sphere,  in  particular  through  hypoplasia  or  atroph}^  of 
the  internallv  secreting  tissues  of  the  ovaries  or  testes.    Where 


Fig.  5. — Facies  in  mild  acromegaly  with  associated  hyperth3Toidia 
of  intermediate  severitj-.     (Mole en.) 

the  pituitar}'  disease  precedes  puberty  the  secondary  sexual 
characteristics  are  often  but  imperfectly  acquired,  while  in 
pituitary  disease  occurring  in  adolescence  or  later,  amenorrhea 
or  impotence  and  retrogressive  change  in  the  essential  sex 
tissues  tend  to  occur. 

Treatment.  Earh-  treatment  of  acromegaly  or  gigantism  is 
possible  relatively  seldom,  because  the  manifestations  of  the 
first  stage  of  the  disease  are,  as  a  rule,  not  such  as  will  bring 
the  patient  to  the  physician  for  treatment;  or,  if  headache 
leads  him  to  seek  medical  advice,  recognition  of  its  true  cause 
may  be  difficult.  Timme,!^^  for  the  early  recognition  of 
pituitary  disturbance — whether  of  the  hyper  or  hypo  type^ — 
emphasizes  attention  to  an  "under  par"  or  overstrung  condi- 
tion, headaches,  a  tendency  to  drowsiness,  hypothermia, 
epistaxis,  dehciency  of  perspiration  even  in  hot  weather,  eyes 


DISEASES    OF    THE    PITUITARY    BODY.  I55 

too  close  or  too  far  apart  to  be  normal,  peculiarities  of  the 
hairy  growth,  and  teeth  abnormal  in  character  or  spacing. 

Given  a  hyperpituitaria  recognized  early,  what  corrective 
non-surgical  measures  are  available? 

As  yet  little  has  been  attempted  save  the  use  of  the  .r-rays 
and  the  administration  .of  palliative  drugs  for  headache. 
While  regarding  the  .i--rays  merely  as  an  adjunct  to  operative 
measures,  Cushingi^^  refers  to  observations  of  Gramegna,^^'^ 
Beclere,!^^  and  Jaugeas,!^^  showing'  that  in  some  pituitary 
tumors  prolonged  .r-ray  treatment  notably  ameliorates  the 
neighborhood  symptoms,  widening,  e.g.,  the  constricted  fields 
of  vision.  In  several  of  his  own  cases,  in  which  pressure- 
symptoms  remained  marked  in  spite  of  partial  operative  evac- 
uation of  the  sella  turcica,  ,t'-ray  treatment  led  to  an  evident 
diminution  of  all  the  pressure  manifestations.  If  such  results 
are  obtainable  even  in  the  more  advanced  cases,  the  method 
should  likewise  be  of  some  avail  in  those  detected  early.  In 
view  of  the  already  well-recognized  efficacy  of  surgical  treat- 
ment, however,  the  latter  should  not  be  postponed  too  long 
where  the  .I'-ray  treatment  proves  inactive.  For  the  relief  of 
headache  in  acromegaly  antipyrin,  acetanilid,  and  acetyl-sali- 
cylic  acid  have  all  been  used  with  considerable,  though  tem- 
porary benefit.  Where  signs  of  excessive  thyroid  activity  co- 
exist, the  therapeutic  measures  appropriate  in  exophthalmic 
goiter  {q.v.)  may  be  applied. 

The  indications  for  surgical  intervention,  as  defined  by 
Cushing,-oo  vary  according  to  the  case.  To  meet  general  pres- 
sure disturbances,  which  may  be  so  marked  as  to  demand 
prompt  relief  before  intervention  on  the  pituitary  itself  can  be 
considered,  a  subtemporal  decompression  operation,  as  for 
other  brain  tumors,  is  recommended.  Sixteen  of  Cushing's  43 
operative  cases  were  subjected  to  this  measure,  usually  before, 
but  occasionally  only  after  an  unavailing  operation  directly  on 
the  pituitary.  In  a  single  case,  an  operation  to  combat  func- 
tional hyperplasia  of  the  pituitary  was  undertaken,  what  was 
thoug"ht  to  be  about  one-third  of  the  anterior  lobe  being  re- 
moved by  Schloffer's  transphenoidal  route.  Subjective  dis- 
comforts and  the  thickening  and  edema  of  the  soft  parts  were 
thus  greatly  improved — though  largely  returning  after  a  year 
— but  no  similar  operations  were  later  undertaken,  it  being 


156  DISEASES    OF    THE    DUCTLESS    GLANDS. 

deemed  uncertain  whether,  in  the  absence  of  hyperplasia  suffi- 
cient to  cause  neighborhood  symptoms,  such  a  procedure  is 
worth  Avhile  from  the  standpoint  of  a  permanent  curative 
action. 

The  chief  indication  for  operative  treatment,  therefore,  is ' 
for  the  purpose  of  relieving  the  neighborhood  symptoms 
caused  by  pressure  of  an  hypophyseal  tumor  on  surrounding 
important  structures.  Even  in  this  connection  the  procedure 
to  be  carried  out  must  vaiy  in  different  cases,  according  to 
the  nature  of  the  lesion.  The  objects  of  the  operation  are 
either  partially  to  remove  the  tumor  or  to  provide  additional 
space  in  the  direction  of  the  least  important  adjoining  struc- 
tures, that  the  tumor,  in  its  further  growth,  may  be  prevented 
from,  endangering  essential  tissues  such  as  the  optic  nerA^es. 

The  earlier  methods  of  surgically  approaching  the  pituit- 
ary- erred  in  their  complexity,  and  in  the  extent  to  which  they 
exposed  the  deep  structures  to  infection.  According  to  V. 
Zachary  Cope,-*^!  two  procedures  have  proven  fairl}-  satisfac- 
tory, viz.,  the  Hirsch-Cushing  submucous  nasal  method  and 
the  fronto-orbital  method  of  Frazier.  Gushing-  gives  to  A.  E. 
Halstead-"-  the  credit  of  first  using  the  sublabial  incision  in 
the  transphenoidal  operation. 

In  the  operation  performed  by  Gushing,  after  institution  of 
intratracheal  anesthesia.'  the  upper  lip  is  raised  and  a  short  in- 
cision made  down  to  the  anterior  nasal  spine  of  the  superior 
maxilla,  the  soft  parts  scraped  back  until  the  cartilaginous  sep- 
tum is  exposed,  and  the  septal  membrane  then  separated  on 
each  side  as  in  submucous  resection.  Upon  insertion  of  a  re- 
tractor 1.8  cm.  in  breadth  and  6  cm.  in  length,  to  separate  the 
freed  layers  of  mucous  membrane,  most  of  the  vomer,  the 
.  lower  edge  of  the  median  plate  of  the  ethmoid,  and  a  small 
strip  of  the  cartilage  are  removed.  A  series  of  dilating  plugs, 
up  to  a  diameter  of  1.8  cm.,  are  now  introduced  to  flatten  the 
turbinates  slightly,  the  retractors  then  withdrawn,  and  a  self- 
holding,  bivalve  speculum,  with  blades  about  7  cm.  long,  in- 
serted. The  sphenoidal  sinuses  having  been  identified,  their 
anterior  and  lower  walls  are  chipped  away  with  long-handled 
nasal  rongeurs,  the  lining  mucosa  of  the  sphenoid  cells  re- 
moved, and  the  floor  of  the  pituitar\^  fossa,  forming  a  pro- 
trusion into  the  cells,  also  chipped  away.     With  a  knife-hook 


DISEASES    OF   THE    PITUITARY    BODY.  157 

a  crossed  incision  is  finally  made  in  the  dura  covering  tlie 
pituitary  or  growth,  and  the  latter  appropriately  dealt  with. 
Termination  of  the  operation  consists  merely  in  checking" 
bleeding"  completely,  withdrawing  the  speculum,  and  closing 
the  lip  incision  by  means  of  2  or  3  catgut  sutures,  without 
drainage.  The  two  layers  of  septal  mucous  membrane,  as  a 
rule  untorn,  fall  together,  and  the  entire  procedure  is  thus  con- 
ducted without  actually  entering-  the  nasal  passages. 

As  for  the  mode  of  dealing  with  the  exposed  pituitary 
lesion,  this  varies  with  the  type  of  lesion  found.  If  a  mere 
infrasellar  tumor  arising  from  an  hypophyseal  rest  is  found, 
it  may  be  forthwith  removed.  Usually,  however,  the  patho- 
logical tissue  is  more  extensive  and  situated  higher.  Gushing 
found  that  even  in  the  presence  of  a  large  pituitary  struma,  a 
simple  sellar  decompression,  as  already  described,  may  suffice 
to  relieve  pressure  against  the  optic  nerves  and  largely  restore 
vision.  In  other  instances,  however,  removal  of  tissue  at  a 
later  operation  is  required.  Whenever  the  nature  of  the  tissue 
exposed  is  in  doubt,  especially  if  there  is  a  possibility  that  it 
may  be  a  flattened  pituitary,  Gushing  advises  abandoning  the 
operation  merely  as  a  sellar  decompression,  and  later  approach- 
ing the  lesion  by  the  intracranial  route  at  a  second  operation. 
In  the  presence  of  a  greatly  enlarged  sella  turcica  filled  with  a 
large  pituitary  struma,  the  part  of  the  tumor  occupying  the 
floor  of  the  sella  is  spooned  out — a  procedure  usually  attended 
with  but  little  bleeding,  as  such  strumas  have  but  little  vas- 
cularity. These  cases  occur  in  considerable  numbers.  Gases 
of  intrapituitary  cyst  are  less  frequent;  their  treatment  con- 
sists in  evacuation. 

Reporting  on  95  operative  cases,  Gushing^os  mentions  Zl 
subtemporal  decompressions  with  2  fatalities,  8  subtemporal 
explorations  without  mortality,  6  subfrontal  explorations  with 
1  death,  16  transphenoidal  decompressions  with  3  deaths,  and 
58  transphenoidal  extirpations,  with  4  deaths.  The  total  oper- 
ative mortality  was  thus  8  per  cent.,  and  the  case  mortality, 
10.5  per  cent.  In  the  last  7)7)  transphenoidal  operations  there 
was  but  1  death — a  mortality  of  only  3  per  cent. 

In  Hirsch's  method  the  middle  turbinates  are  usually  re- 
moved as  a  preliminary  measure  some  days  before  the  main 
operation.     At  the  latter,  performed  under  local  anesthesia, 


158  DISEASES    OF   THE   DUCTLESS    GLANDS. 

the  initial  incision  is  made  through  the  mucous  membrane  over 
the  nasal  septum,  on  one  or  the  other  side.  Special  precautions 
are  taken  to  insure  asepsis.  The  exposure  of  the  pituitary  is 
transphenoidal,  as  in  Cushing's  procedure.  Of  26  cases  thus 
■dealt  with,  4  succumbed  as  a  result  of  the  operation. 

In  spite  of  Cushing-'s  excellent  results,  Cope-*^-*  maintains 
that  there  must  always  be  a  slight  danger  of  meningitis  in  the 
submucous  pituitary  operation,  owing  to  the  fact  that  the 
sphenoidal  ostia  open  into  the  nose.  After  performing  three 
operations  by  the  fronto-orbital  method  of  Frazier,  he  is  in- 
clined to  believe  the  latter  more  suitable  than  the  submucous 
procedure  in  the  great  majority  of  cases.  In  the  fronto-orbital 
method  the  relation  of  the  frontal  sinuses  to  the  supra-orbital 
margin  is  first  ascertained  by  transillumination.  An  osteo- 
plastic flap  is  then  formed  in  the  frontal  region,  the  incision 
starting  at  the  external  angular  process,  coursing  through  the 
eyebrow  line  to  the  root  of  the  nose,  ascending  to  within  the 
hair  line,  turning  outward  again,  and  returning  to  the  temporal 
region  on  a  level  with  the  beginning  of  the  incision.  In  form- 
ing the  bone  flap  the  outer  portion  of  the  supra-orbital  ridge 
is  removed  as  a  wedge-shaped  piece.  The  periosteum  is  then 
freed  from  the  roof  of  the  orbit,  the  roof  removed  with  ron- 
geurs back  to  the  optic  foramen,  and,  if  necessary,  a  small 
opening  made  in  the  dura  to  permit  cerebrospinal  fluid  to 
escape,  and  thus  allow  greater  displacement  of  the  frontal  lobe. 
The  orbital  contents  are  drawn  downward  and  outward  with 
flat  retractors,  the  frontal  lobe  with  its  dural  covering  raised, 
and  the  dura  then  incised  horizontally,  about  a  centimeter 
above  the  base  of  the  skull,  suf^cientl}^  to  admit  a  retractor 
and  expose  the  contents  of  the  sella. 

Advantages  claimed  for  the  fronto-orbital  route  are,  that 
it  provides  an  aseptic  route,  that  it  allows  each  step  of  the 
operation  to  be  performed  under  direct  vision,  and  that  since 
the  primary  enlargement  of  pituitaiy  tumors  is  towards  the 
brain,  the  organ  is  thus  an  easier  object  for  attack  than  it  is 
from  the  infrasellar  exposure.  Tabulating  the  operative  re- 
sults of  the  fronto-orbital  method.  Cope  cites  Frazier's  series 
of  4  cases  without  mortality,  Cushing's  series  of  16  cases  with 
1  death,  and  Sargent's  3  cases  with  1  death,  the  total  mortality 
being-  thus  8.6  per  cent. 


DISEASES    OF   THE    PITUITARY    BODY.  159 

The  possible  ultimate  results  from  hypophyseal  operations 
are  illustrated  in  2  out  of  3  cases  of  pituitary  cyst  dealt  with 
by  Kanavel.-^-^  Stress  is  laid  on  the  fact  that  these  cysts  act- 
ually arise  through  inclusion  of  buccal  epithelium  in  the  hypo- 
physeal reg^ion,  the  remains  of  Rathke's  pouch,  e.g.,  persisting 
near  the  infundibulum,  and  later  proliferating-  to  form  cystic 
or  adamantine  tumors,  hitherto  reported  under  various  titles, 
such  as  epithelial  tumors  of  the  infundibulum,  papilloma  of  the 
choroid  plexus,  cystic  endothelioma  of  the  pia,  adenoma, 
adenosarcoma,  dermoids,  etc.  The  epithelial  inclusions  form- 
ing- the  starting--point  of  such  tumors  reach  the  pituitary  from 
the  craniopharyngeal  duct,  -which  in  the  embryo  forms  a 
passage  from  pharynx  to  brain  cavity  traversing  the  sphenoid 
bone.  In  Kanavel's  operative  procedure  the  incision  is  made 
in  the  crease  of  the  skin  immediately  under  the  nares  and 
alse  of  the  nose.  The  nasal  spine  is  then  cut,  and  the  mucous 
membrane  carefully  raised  from  the  floor  of  the  nose  and  off 
of  the  septum,  back  to  the  sphenoid  bone,  and  off  from  the 
front  of  the  latter.  The  pituitary  is  no-w  exposed  through  the 
sphenoid  as  in  Cushing's  operation.  In  the  first  of  Kanavel's 
cases  the  cyst  found  -was  thoroughly  curetted,  -with  the  result 
of  bringing  the  existing  typical  Frohlich  syndrome  to  a  stand- 
still, and  relieving  the  marked  signs  of  intracranial  pressure. 
Dried  pituitary  gland  -was  fed  for  ovgr  three  years.  Six  years 
after  the  operation  the  patient  -was  still  living  and  -well.  The 
second  case  succumbed  to  meningitis  after  the  operation,  -while 
the  third  -was  operated  upon  on  three  successive  occasions  for 
pressure  relief,  -with  ultimate  recovery.  Three  years  after 
operation  there  had  been  no  recurrence  of  symptoms. 

Postoperative  .r-ray  treatment  is  often  resorted  to  by  Gush- 
ing, especially  in  cases  of  rapidly  enlarging  pituitary  struma. 
The  exposures  are  made  on  alternate  days,  through  the  nares 
and  over  the  temple.  A  previous  sellar  decompression  per- 
mits of  direct  impingement  of  the  rays  on  the  denuded  lesion, 
-while  after  a  temporal  decompression  the  resulting  bone  de- 
fect is  believed  to  render  the  lateral  application  of  the  rays 
more  effectual  than  -would  other-wise  be  the  case. 

The  non-surgical  treatment  of  the  secondary,  hypopituitaric 
stage  of  acromegaly,  in  particular  by  organic  products,  will 
be  described  in  the  succeeding  section. 


160  DISEASES    OF    THE    DUCTLESS    GLANDS. 

PITUITARY  INSUFFICIENCY  (HYPOPITUITARIA). 

Apart  from  the  rather  numerous  cases  in  which  pituitary 
insuiticiency  becomes  manifest  as  a  secondary  phase  of  hypo- 
physis disease — i.e.,  in  which  signs  of  acromegaly  have  pre- 
ceded those  of  insufificiency — there  occur  cases  in  which  evi- 
dences of  deficient  pituitary  activity  characterize  the  clinical 
picture  from  the  beginning.  Where  the  morbid  process  has 
become  established  in  childhood,  the  so-called  Frohlich's  syn- 
drome, or  dystrophia  adiposogenitalis,  is  the  result,  marked 
not  only  by  adiposity,  but  also  by  a  persistence  of  infantile  skele- 
tal and  sexual  conditions.  Where,  on  the  other  hand,  it  begins 
in  the  adult,  the  sexual  infantilism  is  produced  through  re- 
version from  the  conditions  normal  in  this  period  of  life,  the 
adiposity,  however,  being  present  as  in  the  Frohlich  syndrome. 
According  to  Cushing,206  i^ue  strumas  of  the  hypophysis 
causing  functional  insufficiency  are  most  frequently  met  with 
in  the  third  and  fourth  decades  of  life.  Extrapituitan'  tumors, 
on  the  other  hand,  arising  congenitally  in  the  sphenoidal  or 
infundibular  regions,  are  apt  to  cause  symptoms  in  the  earlier 
decades,  compromising  the  functional  activities  of  the  hypo- 
physis from  the  very  beginning. 

Characteristic  of  the  Frohlich  disease  is  the  peculiar  nat- 
ure of  the  adiposity,  whjcli,  in  males,  affects  a  feminine  type 
of  distribution.  Coupled  with  it  occur  hypotrichosis,  hypo- 
thermia, hypoplasia  of  the  genitals,  a  low  stature,  psychoses  of 
varying  t\'pes,  and  an  abnormally  high  carbohydrate  tolerance. 
Of  these  phenomena,  the  adiposity  and  the  heightened  carbo- 
hydrate tolerance  are  particularly  ascribed  to  insufficiency  of 
the  posterior  lobe  by  Cushing.  The  hypothermia,  genital 
modifications,  and  general  undergrowth,  on  the  other  hand, 
are  especially  attributed  to  inactivity  of  the  anterior  lobe. 
The  adiposity  in  Frohlich's  syndrome  is  not  infrequently  asso- 
ciated with  polyphagia,  and  especially  an  abnormal  desire  for 
sweets.  The  mental  state  is  characterized  by  torpor,  drowsi- 
ness, and  constant  lassitude.  ^Metabolism  is  slow,  and  the 
urinary  solids  reduced,  though  the  amount  of  urine  is  some- 
times increased.  The  external  genitals  are  of  small  size,  with 
the  pubic  hair  scanty  or  wanting.  Cn,^ptorchism  or  an  infan- 
tile uterus  may  exist  and  give  rise,  respectively,  to  impotence 


DISEASES    OF   THE    PITUITARY    BODY.  161 

or  amenorrhea.  If  amenorrhea  be  not  complete,  the  menses 
may  appear  late,  and  the  flow  be  irregular  or  scanty.  Women 
developing-  hypopituitaria  after  puberty  cease  to  menstruate. 
The  skin  is  dry,  even  in  hot  weather  and  during"  exertion,  and 
generally  smooth,  though  that  of  the  backs  of  the  hands  may 
be  wrinkled.  The  general  asthenia  affects  the  involuntary 
muscles  as  well  as  voluntary  motion,  constipation  being  a  fre- 
quent accompaniment.  The  pulse  is  often  slow  and  of  small 
volume,  the  blood-pressure  lo'W,  and  the  limbs  cold  and  at 
times  edematous.  • 

Laying  stress  upon  the  features  permitting  of  early  detec- 
tion of  hypopituitaria,  Timme-^^  specifies  as  suggestive  of  this 
condition  in  the  preadolescent  period  a  small  stature,  adiposi- 
ties, ununited  epiphyses,  small  sexual  organs,  weak  skeletal 
muscles,  malformed  and  irregularly  placed  teeth,  a  progna- 
thous upper  maxillary  and  deficient  general  bony  structure, 
narrowing  of  the  interval  between  the  eyes,  unusually  small 
hands  and  feet,  and  weakness  of  the  bladder  walls  leading  to 
enuresis.  The  child  cries  easily,  is  apt  to  be  cowardly,  and 
gets  along  with  his  playmates  only  with  difficulty.  He  is 
mentally  and  physically  sluggish,  lacks  self-confidence,  and  is 
backward  at  school.  Where  several  of  these  symptoms  exist 
in  one  individual,  Timme  believes  the  presumption  strong  that 
pituitary  deficiency  is  present.  Occasionally  such  children 
have  epileptic  attacks,  at  times  merely  in  the  form  of  dreamy 
periods  associated  with  gustatory  and  olfactory  impressions. 
In  d3'spituitaria  a  general  status  thymicolymphaticus  with  ex- 
cessive adenoid  formation,  frequent  nosebleeds,  and  intermit- 
tent mucous  discharges  into  the  pharynx  also  has  been  seen. 

A  special  form  of  preadolescent  hypopituitaria — the  Lorain 
type — is  distinguished  in  which,  though  genital  dystrophy  and 
deficient  growth  exist,  adiposity  is  absent  or  inconspicuous. 
According  to  Cushing's  conceptions  of  the  functions  of  the 
dift'erent  portions  of  the  pituitary,  this  condition  would  be  due 
chiefly  to  insufficiency  of  the  anterior  lobe.  One  of  his  cases 
illustrating  this  affection  concerned  a  female  patient  of  20 
years  and  6  months,  undersized  (4  feet  4  inches),  weak  and 
delicate,  with  the  bodily  proportions  of  an  adult  rather  than 
of  infancy,  but  with  absence  of  secondary  sexual  characteris- 
tics.   Many  similar  instances  have  been  reported  in  which,  ap- 


162  DISEASES    OF    THE    DUCTLESS    GLANDS. 

parently  as  a  result  of  decreased  functioning  of  the  anterior 
pituitary  early  in  life,  cessation  of  growth  occurred  at  the  age 
of  10  or  12  years,  a  species  of  pituitary  (hypophyseal)  nanism 
or  infantilism  resulting.  In  the  case  recorded  by  Evans  and 
Assinder,-"'^  the  condition  was  believed  to  have  originated  in 
a  fall  on  the  forehead  at  the  age  of  5,  attacks  of  headache  and 
drowsiness  soon  following,  growth  ceasing  at  12  or  14  years. 
Diabetes  insipidus  has  been  noted  in  association  wnth  the 
pituitar}"  symptoms  and  ascribed  to  the  disease  of  this  organ. 

Special  stress  has  been  laid  by  Sajous,  Sr.,209  q^  deficient 
activity  of  other  ductless  glands  in  the  pathogenesis  of  the 
d3'Strophia  adiposogenitalis,  the  hypopituitaria  entailing  a 
pluriglandular  deficiency  because  of  impairment  of  the  func- 
tion of  the  pituitar}'  as  a  governing  center  of  endocrine  organs. 
Thus,  the  subnormal  temperature,  low  blood-pressure,  and 
occasional  skin  pigmentation  of  hypopituitaria  are  ascribed  to 
secondarily  deficient  activity  of  the  adrenal  medulla ;  the  mus- 
cular weakness,  scanty  hair  growth,  and  undeveloped  or  in- 
fantile genital  organs,  to  deficiency  of  the  adrenal  cortex ;  the 
adiposis,  smoothness,  and  dryness  of  the  skin  to  deficiency  of 
the  thyroid,  and  the  undersized  growth,  with  deficient  skeletal 
development  and  imperfect  epiphyseal  ossification,  to  pre- 
adolescent  insufliciency  of  the  thymus. 

The  cause  of  the  pituitary  impairment  being,  as  a  rule,  some 
form  of  growth  in  this  organ  or  in  adjacent  structures,  marked 
symptoms  of  pressure,  on  surrounding  tisues  are  to  be  ex- 
pected sooner  or  later.  These  symptoms  have  already  been 
enumerated  under  Pituitar}-  Overactivity,  including  especially 
headache,  bitemporal  hemianopsia,  strabismus,  the  epileptoid 
seizures  already  referred  to,  papilledema,  blindness,  and  some- 
times vomiting.  Xot  infrequenth^  indeed,  the  pituitar}^  nature 
of  the  disease  has  remained  unrecognized  until  advanced  pres- 
sure manifestations  such  as  these  have  been  complained  of. 
L.  J.  Pollock^io  has  called  attention  to  the  frequency  of  chronic 
hydrocephalus  as  a  cause  of  hypopituitaria,  having  obsen^ed 
12  such  cases  in  two  years.  In  all  these  cases  adipositv  was 
the  predominating  feature.  All  cases  likewise  showed  delicate, 
pudg}';  tapering  hands  with  broad  bases.  Genital  hypoplasia, 
however,  was  observed  but  once.  Each  of  6  cases  specially  ex- 
amined showed  increased  carbohydrate  tolerance. 


DISEASES   OF  THE   PITUITARY   BODY.  163 

TREATMENT. 

The  treatment  of  hypopituitaria  comprises  (1)  the  meas- 
ures necessary  to  relieve  pressure-symptoms  caused  by  the 
associated  pituitary  or  extrapituitary  enlargement  or  tumor ; 
(2)  those  required  to  make  up  for  deficient  pituitary  functions. 

The  first  group  of  measures  includes  both  non-operati\'e 
and  operative  procedures.  Among  the  former,  thyroid  prep- 
arations have  so  far  played  a  rather  important  role.  While 
good  results  from  them  are  by  no  means  regularly  to  be  ex- 
pected, many  cases  have  been  reported  in  which  benefit  fol- 
lowed their  use,  especially  as  regards  the  visual  impairment. 
Thus,  Thomson  and  Lang^n  report  4  cases  of  pituitary  disease 
in  which  visual  failure  had  occurred  some  time  before  thyroid 
treatment,  and  yet  was  largely  overcome  by  this  agent.  These 
authors  refer  also  to  cases  of  similar  visual  improvement  wit- 
nessed by  Fisher  and  by  de  Schweinitz,  the  latter  using  mer- 
curial inunctions  along  with  large  doses  of  thyroid  extract. 
To  account  for  the  benefit  from  such  preparations,  Thomson 
and  Lang  assert  that  since  in  cretins  and  thyroidectomized 
animals  the  pituitary  tends  to  increase  in  size,  one  may  well 
believe  that  a  therapeutic  hyperthyroidism  is  sometimes  ac- 
companied by  a  diminution  of  the  size  of  an  enlarged  pituitary. 
Observation  seems  to  have  shown,  we  may  add,  that  this 
shrinking  effect  of  thyroid  treatment  on  a.  pituitary  enlarge- 
ment may  occur  whether  the  manifestations  of  pituitary  dis- 
ease at  the  time  be  those  of  hyperpituitaria  (acromegaly)  or  of 
hypopituitaria.  In  a  case  of  acromegaly  reported  by  Salo- 
mon,-^ 2  all  the  symptoms  became  considerably  worse  when 
the  patient  took  pituitary  extract,  yet  thyroid  medication 
caused  instead  a  disappearance  of  the  headache,  dizziness,  and 
vomiting  and  an  improvement  in  the  mental  condition.  The 
view  of  Sajous,  Sr.,  that  it  is  in  reality  through  other  ductless 
glands,  including  the  thyroid,  that  the  pituitary  produces  its 
morbid  effects,  best  explains  the  beneficial  efifects  of  thyroid 
gland  in  hypopituitaria. 

The  T-ray  treatment  of  pituitary  enlargement  has  already 
been  referred  to  under  J-Iyperpituitaria.  Kupferle  and  von 
Szily'^13  have  reported  a  case  of  "cancer"  of  the  hypophysis  in 
which,  six  months  after  operative  removal,  vision  again  began 


164  DISEASES   OF   THE   DUCTLESS    GLANDS. 

to  fail  rapidly  and  the  a'-ray  shadow  of  the  recurring  tumor 
increased  in  size.  Even  after  the  beginning-  of  the  .r-ray  treat- 
ment vision  diminished  further  until  completely  lost.  Upon 
continuing  the  .I'-ray  treatment  two  months,  however,  sight 
gradually  returned  up  to  6/24  in  one  eye,  and  at  the  time  of 
writing  this  condition  had  been  maintained  unchanged  for 
seven  months.  Mesothorium  treatment  in  the  pharjmx  was 
combined  in  this  case  with  the  ,^•-rays  used  externally.  T.  A. 
AMlliams^i^  has  reported  what  was  apparently  a  case  of  neo- 
plasm causing  pressure  on  the  hypophysis,  with  severe  cen- 
tral headache,  temporary  diplopia,  dizziness,  restricted  and  in- 
terlaced visual  fields,  increased  sugar  tolerance,  spasticity,  and 
exaggerated  reflexes,  in  which,  as  a  result  of  numerous  ,i'-ray 
exposures  in  the  course  of  eighteen  months,  headache  had 
ceased  for  a  year,  the  visual  fields  expanded  over  a  year  and 
finally  returned  to  normal,  the  spasticity  disappeared,  and  cer- 
tain uncinate  phenomena  experienced  by  the  patient  passed 
oiT.  An  apparent  difference  in  the  field  of  applicability  for  thy- 
roid and  A--ray  treatment  in  such  cases  is  that  whereas  the 
former  is  available  only  for  true  pituitary  enlargements,  the 
latter  is  likewise  applicable  to  extrapituitary  tumors  causing 
pituitary  symptoms  merely  through  pressure  on  the  hypo- 
physis. 

In  a  case  of  typical  hypopituitaria  in  a  boy  of  18  recorded 
by  Leszynsky,2i5  in  which  the  pressure-symptoms  were 
ascribed  to  internal  hydrocephalus,  puncture  of  the  corpus  cal- 
losum  to  establish  permanent  subdural  drainage  resulted  in 
ten  days  in  a  disappearance  of  all  the  symptoms  of  intraven- 
tricular pressure,  and  one  year  after  the  treatment  a  consider- 
able improvement  in  the  visual  function  had  taken  place.  In  a 
similar  case  in  a  child  mentioned  by  Spiller,2i6  with  marked 
pituitary  symptoms,  increased  sugar  tolerance  and  eye  symp- 
toms, callosal  puncture  relieved  the  ocular  disturbances,  but 
not  the  general  condition. 

By  far  the  most  reliable  treatment  for  the  pressure-symp- 
toms of  pituitary  enlargements  is  surgical  operation.  The  in- 
dications and  technic  of  the  operative  treatment  have  already 
been  described  under  Hyperpituitaria  (q-v.). 

For  the  symptoms  of  hypopituitaria  glandular  therapy  is 
manifestly  indicated,  and  its  efficacy  is  supported  by  animal 


DISEASES    OF   THE    PITUITARY    BODY.  165 

experiments,  Gushing-  having  found  that  hypophysectomized 
dog's  could  be  benefited  by  injection  of  pituitary  extracts, 
glandular  feeding-  or  hypophyseal  implantations."  After  com- 
plete pituitary  removal,  subcutaneous  or  intravenous  injec- 
tion of  the  emulsion  of  a  single  fresh  pituitary  often  aroused 
to  apparently  normal  activity  an  already  hypothermic,  som- 
nolent animal.  In  animals  from  which  nearly  all  the  organ  had 
been  removed,  organic  therapy  bridged  over  the  critical  post- 
operative period,  gi^ang  time  for  the  remaining  pituitary  tis- 
sue to  undergo  hypertrophy. 

In  clinical  pituitary  medication,  some  degree  of  differentia- 
tion as  regards  the  use  of  one  or  the  other  lobe,  or  both,  is 
considered  possible,  the  anterior  lobe  being  especially  indicated 
in  the  presence  of  insufficient  bodily  growth,  hypothermia, 
hypotrichosis,  and  impaired  genital  activity,  while  the  tend- 
ency to  adiposity  and  the  abnormal  carbohydrate  tolerance 
are  most  favorably  infiuenced,  it  is  claimed,  by  ingestion  of 
the  posterior  lobe.  In  cases  showing  signs  of  deficiency  of 
both  the  anterior  and  the  posterior  lobes,  a  combined  extract 
of  the  whole  gland  is  logically  indicated.  In  cases  in  which 
the  pituitary  disturbance  has  resulted,  through  primary  over- 
activity, in  gigantism  or  acromegaly,  it  is  of  course  essential 
to  be  certain  that  the  second  stage  of  hypopituitaria  has  actu- 
ally been  reached  before  administering  pituitary  products,  lest 
the  treatment  bring  about  aggravation  rather  than  relief.  In 
most  cases  in  which  abnormal  pressure  is  being  exerted  on  the 
pituitary,  both  lobes  of  the  gland  are  impaired  or  destroyed ; 
whole  pituitary  administration  is  therefore  oftener  indicated 
than  the  use  of  but  one  lobe.  In  deficient  stature  due  to  pituit- 
ary insufficiency  the  chances  of  improvement  from  organo- 
therapy vary  according  to  the  condition  of  the  epiphyses  at  the 
time.  If  these  are  as  yet  ununited,  as  shown  by  .f-ray  exami- 
nation, success  in  increasing  the  stature  may  reasonably  be 
expected,  but  if  they  are  already  completely  united,  little  is  to 
be  hoped  for  from  pituitary  treatment. 

In  the  successful  cases  of  pituitary  feeding,  a  variety  of 
beneficial  results  may  be  noted.  The  subnormal  body  tem- 
perature tends  to  return  to  normal,  the  blood-pressure  to  rise, 
the  constipation  to  be  corrected,  and  the  patient's  mind  to  be 
roused  from  its  lethargy  and  drowsiness.    In  one  of  Cushing's 


166  DISEASES    OF    THE    DUCTLESS    GLANDS. 

cases, -1"  menstruation  became  re-established  under  the  treat- 
ment after  a  year  of  amenorrhea.  In  a  male  patient,  under 
surgical  and  organotherapeutic  treatment,  libido  and  potency 
returned  after  a  long  period  of  abeyance.  In  some  instances, 
a  considerable  loss  of  weight  took  place,  though  in  but  a  few 
was  the  adiposity  completely  overcome.  In  some  epileptoid 
cases,  possibly  based  on  pituitary  disturbance,  improvement 
occurred  under  pituitary  treatment.  Yet  in  many  cases  the 
results  of  pituitar}-  medication  have  proved  partly  disappoint- 
ing. Kanavel,2i8  in  an  operated  case  of  cyst  of  the  hypo- 
physis with  typical  Frohlich  syndrome  in  which  pituitary 
medication  was  applied  for  three  years,  at  first  with  the  ante- 
rior lobe  alone,  and  later  with  the  whole  organ,  obser^'ed  a 
distinct  growth  of  hair,  but  no  evidence  of  growth  in  height 
(4  feet  9  inches)  or  size,  no  appearance  of  genital  function,  and 
no  growth  in  the  size  of  the  testicles.  The  voice  did  not  be- 
come more  masculine.  The  excessive  adiposity,  however,  was 
lost,  and  the  polyuria  and  acetonuria  disappeared,  though 
sugar  tolerance  remained  above  normal  after  two  years.  The 
impairment  of  vision  previously  existing  persisted,  but  with- 
out increasing. 

In  general,  the  best  results  from  pituitary  medication,  which 
Sajous,  Sr.,  ascribes  to  the  adrenal  principle  in  organic  combina- 
tion indicated  by  tests  to  exist  in  the  pituitar}^,  seem  obtainable 
only  after  prolonged  treatment.  The  dosage,  however,  is  an- 
other important  consideration,  and  proper  management  in  this 
respect  was  found  by  Gushing  a  matter  of  some  difficulty 
owing  to  the  great  apparent  variations  in  the  dose  require- 
ments in  different  cases.  AA^hereas  a  number  of  cases  showed 
improvement  under  18  grains  of  desiccated  bovine  pituitary 
daily,  others  needed  larger  amounts,  and  in  1  case  a  dosage 
of  20  grams  (300  gr.)  daily — prohibitive  for  continued  use 
owing  to  its  cost — was  found  necessary  to  yield  subjective 
benefit.  The  Armour  0.2-gram  (3-gr.)  tablets,  whether  of 
whole  gland  or  anterior  or  posterior  lobe,  actually  contain,  ac- 
cording to  Gushing,  but  0.06  gram  (1  gr.)  of  the  dried  bovine 
pituitar\\  A  patient  using  6  tablets  a  day  would  therefore  be 
taking  in  0.4  gram  (6  gr.)  of  pituitary  substance.  Each  0.06  gram 
(1  gr.)  of  dried  substance,  however,  represents,  according  to 
Gushing,  the  extractives  of  about  5  fresh  bovine  pituitaries. 


DISEASES    OF   THE    PITUITARY    BODY.  167 

The  patient  would,  therefore,  be  ingesting  daily  the  equivalent 
of  30  bovine  pituitaries.  To  ascertain  the  proper  dosage  in  a 
given  case.  Gushing  has  resorted  to  the  expedient  of  giving  the 
subject  daily  an  amount  of  glucose  or  levulose  sufficient  to 
produce  a  temporary  mellituria  in  a  normal  person  of  equal 
body  weight;  meanwhile  an  increasing  amount  of  pituitary 
extract — particularly  posterior  lobe — is  given  daily,  until  a 
trace  of  sugar  appears  in  the  urine.  The  proper  pituitary- 
dosage  is  thus  estimated  by  the  degree  of  sugar  tolerance, 
that  dose  of  the  remedy  being  adopted  which  will  reduce  the 
patient's  excessive  tolerance  to  normal.  In  some  cases,  how- 
ever, even  with  an  enormous  dosage  of  pituitary  substance,  it 
proved  impossible  to  produce  a  levulosuria  with  normal 
amounts  of  levulose. 

Because  of  the  prohibitive  expense  or  incomplete  effective- 
ness of  pituitary  preparations  in  some  cases,  polyglandular 
therapy  has  been  resorted  to.  Admitting  that  the  malady  in 
hypopituitaria  is  a  polyglandular  one,  Cushing^io  himself  con- 
cluded that  the  administration  of  extracts  of  other  ductless 
glands  might  be  of  service.  Of  his  patients  a  number  were 
definitely  improved  by  thyroid  treatment.  Again,  in  the  case 
of  a  eunuchoid  giant  with  asthenia,  low  blood-pressure,  and 
pigmentation,  marked  benefit  was  obtained  from  adrenal  ad- 
ministration. A.  S.  Cobbledick,220  in  a  case  of  lesion  of  the  left 
optic  tract  attributed  to  a  pituitary  growth  (the  feet  and  hands 
subsequently  enlarging),  with  distinct  evidences  of  myxedema, 
noted  improvement  in  the  memory  and  in  the  patient's  numb- 
ness when  thyroid  medication  was  applied.  As  already 
pointed  out,  Sajous,  Sr.,221  ascribes  many  of  the  manifesta- 
tions of  hypopituitaria  largely  to  accompanying  secondary  de- 
ficiencies of  the  thyroid,  adrenals,  and  thymus.  Even  for  the 
treatment  of  an  apparently  pure  hypopituitaria,  therefore,  he 
combines  with  the  pituitary  medication  0.06  gram  (1  gr.)  of 
dried  thyroids  and  0.12  gram  (2  gr.)  of  dried  thymus  three 
times  a  day.  The  activity  of  pituitary  substance  seems  to  be 
enhanced  when  small  doses  of  thyroid  are  combined  with  it. 

Subcutaneous  or  intramuscular  administration  of  pituitary 
preparations  is  available  where  results  from  oral  use  prove 
insufficient.  In  experimental  hypopituitarism  in  dogs,  Goetsch 
found  subcutaneous  injections  of  posterior  lobe  extract  about 


168  DISEASES    OF    THE    DUCTLESS    GLANDS. 

four  times  as  effective  as  introduction  by  mouth  in  lowering 
the  assimilation  limit  for  sugars.  In  one  of  Cushing's  cases--- 
subcutaneous  injection  of  0.2  gram  (3  gr.)  of  boiled  anterior 
lobe  extract  caused  a  rise  in  temperature  of  nearly  3°  F.,  in- 
creased moisture  of  the  skin,  a  marked  lessening  of  the  copious 
urinary  secretion,  and  a  striking  resuscitation  from  the  previ- 
ous stuporous  condition,  with  increased  appetite.  This  patient 
improved  under  oral  administration.  In  another  case,  how- 
ever,---5  even  large  doses  of  pituitar}^  extract  by  mouth  yielded 
little  improvement;  yet  daily  injections  of  boiled  whole  gland 
extract  in  a  dosage  representing  0.12  gram  (2  gr.)  of  the  dried 
preparation  roused  the  patient,  previously  in  a  state  of  som- 
nolence approaching  unconsciousness,  to  such  an  extent  that 
for  two  weeks  he  seemed  normally  active,  both  mentally  and 
physically.  Because  of  increasing  soreness  from  the  injec- 
tions, these  were  then  discontinued,  and  the  hypophysis  of  a 
newborn  child,  the  victim  of  a  birth  hemorrhage,  was  im- 
planted in  the  subcortex  of  the  temporal  lobe  at  the  point  of 
a  previous  decompression  operation.  Interruption  of  the 
pituitary  injections  not  being  followed  by  a  relapse  into  the 
former  somnolence,  the  conclusion  was  reached  that  the  im- 
planted tissue  had  remained  viable. 

DISEASES  OF  THE  PINEAL  GLAND. 

Located  below  the  splenium  of  the  corpus  callosum,  with 
its  base  directed  anteriorly  and  fixed  to  the  habenular  com- 
missure and  the  posterior  commissure  above  the  opening  into 
the  aqueduct  of  Sylvius,  the  pineal  constitutes  the  remains  of 
a  special  visual  organ  in  certain  invertebrates  and  low  verte- 
brates. In  the  higher  vertebrates,  nearly  all  the  structural 
peculiarities  of  a  definite  sense  organ  have  been  lost,  and  the 
main  histological  features  are  those  of  a  gland.  The  paren- 
chyma consists  of  irregular  lobes  or  follicles  supported  by  a 
small  quantity  of  connective  tissue,  and  the  glandular  cells 
themselves  contain  characteristically  large  nuclei  with  their 
periphery  crowded  with  granules.  The  so-called  "pineal  sand," 
consisting  of  calcium  phosphate  and  carbonate,  occurs  merely 
in  the  glial  stratum  overlying  the  habenular  commissure.  The 
pineal,  as  described  by  Jordan--^  in  sheep  fetuses  nearly  at 


DISEASES    OF   THE    PIXEAL   GLAND.  169 

full  term,  is  a  hig-hly  vascular  organ,  the  capillaries  in  places 
forming  glomerular  loops  in  spaces  surrounded  by  paren- 
chyma more  compact  than  elsewhere  in  the  body.  Jordan 
noted  also  a  few  white  nerve  fibers,  and  states  that  the  frame- 
work of  the  parenchyma  is  a  reticulum  of  delicate  neuroglia 
fibers,  for  the  most  part  continuous  with  stellate  neuroglia 
cells.  Ramon  y  Cajal--^  also  found  sympathetic  fibers  in  the 
gland,  forming  a  plexus  close  to  the  gland-cells. 

Involutional  changes  in  the  pineal  body  begin  relatively 
early  in  life.  In  man  it  is  believed  to  be  functionally  most 
active  in  the  seventh  year  of  life.  From  then  on  it  undergoes 
retrograde  modifications  characterized,  according  to  Jordan's 
investigations  in  sheep,  by  a  marked  increase  in  connective  tis- 
sue and  a  cellular  neuroglia  network,  and  a  reduction  in  the 
g'land  parenchyma.  The  gland  does  not,  however,  degenerate 
completely,  and  the  possibility  of  functional  activity  on  its 
part  in  adult  life  is  not  excluded.  According  to  Krabbe,  the 
evidences  of  involution  in  extreme  old  age  are  no  more  marked 
than  in  the  fourteenth  year. 

Experimental  removal  of  the  pineal,  a  difficult  operative 
procedure,  in  itself  frequently  followed  by  death,  has  shown, 
in  the  successful  cases,  that  the  organ  is  not  essential  to  life. 
Apart  from  this,  the  results  have  been  contradictory. 
Dandy,226  removing  the  pineal  in  dogs  through  the  third  ven- 
tricle after  incising  the  splenium  of  the  corpus  callosum,  noted 
none  of  the  changes  observed  by  certain  other  investigators 
after  pinealectomy,  and  found  nothing  to  sustain  the  view  that 
the  organ  has  any  active  endocrine  function  of  importance, 
either  in  very  young  or  adult  dogs.  On  the  other  hand,  Hor- 
rac,-^'''  reproducing  in  guinea-pigs  the  results  previously  ob- 
tained by  a  number  of  other  investigators  in  these  and  other 
experimental  animals,  found  that  pinealectomized  male  guinea- 
pigs  show  a  hastened  development  of  the  sexual  organs,  and 
females  a  tendency  to  breed  earlier  than  controls  of  the  same 
age  and  weight.  Other  experimenters  have  in  some  instances 
noted  a  temporary  acceleration  of  body  growth  as  a  whole 
after  pinealectomy,  with  subsequent  gradual  subsidence  to  the 
average  weight  of  controls.  Experimental  results  such  as 
these  led  Pellizzi^ss  ^q  ^he  hypothesis  that  the  function  of  the 
pineal  body  is  to   exercise   a  moderating  action   on   genito- 


170  DISEASES   OF   THE   DUCTLESS   GLANDS, 

somatic  development.  According  to  Foa,229  pinealectoitty  in 
rats  does  not  determine  an  absolute  hypertrophy  of  the  testes, 
but  a  premature  development  of  them. 

Feeding  experiments  with  pineal  substance,  apparently 
contradicting  the  results  from  pinealectomy,  themselves  have 
shown  a  rapid  sexual  and  somatic  development.  Dana  and 
Berkeley,230  administering  pineal  to  kittens  and  to  young 
rabbits  and  guinea-pigs,  observed  a  25  per  cent,  excess  in  the 
weight  of  these  animals  over  that  of  controls.  McCord,23i 
summarizing  the  results  of  experiments  on  400  young  chickens, 
guinea-pigs,  and  dogs,  reports  almost  uniformly  a  more  rapid 
groAvth  of  the  body  than  normal,  with  an  early  sexual  matur- 
ity. The  excess  in  rate  of  growth  was  most  marked — 40.9  per 
cent,  excess  in  eleven  weeks  in  guinea-pigs — in  young  animals 
fed  with  pineal  tissue  from  young  animals.  No  tendency  to 
gigantism,  however,  was  noted,  and  after  maximum  size  was 
attained,  the  pineal  substance  seemed  ineffective.  So  small  an 
amount  of  pineal  gland  as  20  milligrams  (%  gr.)  weekly  proved 
sufficient  to  stimulate  growth  beyond  the  usual  rate.  The  re- 
sponse to  pineal  in  the  rate  of  growth  was  somewhat  more 
definite  in  males  than  in  females.  The  testes  from  pineal-fed 
animals  were  50  per  cent,  larger,  and  showed  premature  and 
very  active  spermatogenesis.  Tadpoles  fed  with  pineal  tissue 
at  first  grew  to  double  the  size  of  controls  fed  with  muscle 
tissue,  and  subsequently  showed  a  markedly  precocious  trans- 
formation into  adult  frogs.  Again,  paramecia  placed  in  hay 
infusion  with  0.05  per  cent,  of  pineal  extract  almost  invariably 
showed  a  more  rapid  rate  of  reproduction  by  transverse  split- 
ting than  controls.  Hoskins,232  feeding  albino  rats  with  thy- 
roid, th3'mus,  hypophysis,  and  pineal  tissues,  was  led,  on  the 
other  hand,  to  conclude  that  none  of  these  organs  has  any 
constant  effect  upon  the  growth-rate  of  young  rats.  More 
recently  McCord  and  Allen^ss  have  reported  finding  that  the 
pineal  contains  a  substance  capable  of  controlling  pigment 
cell  changes  in  tadpoles.  Tadpoles  placed  in  a  1  in  500  pineal 
emulsion  became  in  five  minutes  noticeably  lighter  in  color 
and  more  translucent  than  controls ;  this  effect  attained  its 
maximum  in  y^  an  hour  and  passed  off  in  3  to  6  hours.  Sajous, 
Sr.,  does  not  consider  the  pineal  as  a  ductless  gland,  but  as  a 
neural  organ  probably  of  temporary  use  in  development. 


DISEASES   OF  THE   PINEAL  GLAND.  171 

PINEAL  TUMORS. 

Krabbe,  in  a  paper  published  in  1915,  asserted  that  about 
70  cases  of  pineal  tumor  had  been  recorded  up  to  that  time. 
The  observations  of  a  number  of  cases  of  precocious  sexual 
and  general  body  growth"  in  the  presence  of  a  pineal  tumor  led 
Marburg2o4  ^q  recognize  a  special  clinical  syndrome  associated 
with  pineal  dysfunction.  As  later  developed,  this  syndrome  in- 
cludes :  (1)  general  intracranial  manifestations,  comprising 
the  various  customary  evidences  of  increased  intracranial  pres- 
sure, the  latter  depending,  as  a  rule,  upon  a  secondary  internal 
hydrocephalus ;  (2)  neighborhood  manifestations,  comprising 
especially  evidences  of  encroachment  on  the  corpora  quad- 
rigemina  and  cerebellum,  causing  oculomotor  and  pupillary 
disturbances  together  with  ataxic  phenomena;  (3)  consti- 
tutional or  metabolic  manifestations,  ascribed  directly  to  the 
disturbance  of  pineal  function,  and  characterized  by  early 
growth  and  maturity  of  the  sexual  organs,  with  pubic  and 
general  body  hair,  and  a  premature  change  of  voice ;  an  early 
maturity  of  thought  and  speech,  due  to  precocious  mental  de- 
velopment, and  a  general  overdevelopment  of  the  body  such 
that  the  appearance  of  a  child  of  11  or  12  years  may  be  pre- 
sented by  one  actually  only  5  or  6  years  old.  Frankl-Hoch- 
wart235  also  was  led  to  describe  such  a  condition. 

As  a  matter  of  fact,  however,  only  relatively  few  of  the 
pineal  tumor  cases  have  actually  exhibited  these  manifesta- 
tions of  precocity.  Only  25  of  Krabbe's  70  cases  occurred  be- 
fore puberty,  and  of  these  only  a  minority  showed  such 
changes.  According  to  some — e.g.,  Bailey  and  JellifTe^sc — the 
metabolic  symptoms  that  may  result  from  pineal  involvement 
comprise  not  only  sexual  precocity,  but  also  adiposis  (one 
form  of  "adipositas  cerebralis"),  and  in  some  instances 
cachexia.  Again,  available  facts  seem  insufficient  to  demon- 
strate whether  the  precocity  and  other  manifestations  are  act- 
ually due  to  an  excessive  or  deficient  function  of  the  pineal. 
Bailey  and  Jellifife  state  that  neither  the  sexual  precocity  nor 
the  cachexia  can  be  precisely  accounted  for,  nor  can  it  be  stated 
definitely  whether  disturbed  pineal  function  alone  is  capable 
of  causing  adiposis,  or  whether  the  latter  is  due  to  concomi- 
tant hydrocephalus  of  the  third  ventricle,  exerting  pressure  on 


172  DISEASES   OF  THE  DUCTLESS   GLAXDS. 

the  pituitary.  If  hypopituitaria  is  to  account  for  the  adiposis, 
it  will  not  account  for  the  sexual  precocity,  for  in  the  dys- 
trophia adiposogenitalis  there  is  a  lack  of  sexual  development. 
Gushing  holds  that  the  pituitar}-  functions  may  easily  be- 
come modified  from  pressure  exerted  on  this  organ  in  the  pres- 
ence of  a  pineal  tumor.  Bailey  and  Jelliflfe--^"  have  described 
a  series  of  manifestations  of  pineal  disease  due  to  such  pres- 
sure on  the  various  structures  surrounding  the  pineal.  Ac- 
cor^iing  to  McCord,  furthermore,  not  enough  attention  has 
l^een  paid  to  possible  hormonic  relationships  of  the  pineal  to 
other  ductless  glands.  Cn  the  whole,  the  entire  subject  of 
pineal  pathology  must  still  be  considered  in  an  indecisive  stage. 
As  AlcCord-'^'^  has  pertinently  remarked,  experimental  evi- 
dence is  available  supporting  both  the  contention  that  pineal 
neoplasms  retard  the  activity  of  this  organ  and  that  they 
increase  it. 

TREATMENT. 

In  the  absence  of  definite  knowledge  as  to  whether  the 
macrogenitosomatic  syndrome  is  due  to  impaired  or  to  en- 
hanced pineal  activity,  or  even  as  to  whether  vagaries  of  the 
pineal  function  are  truly  responsible  at  all  for  such  changes, 
no  rational  treatment  of  gross  pineal  lesions  is  available. 
Operative  removal  of  a  supposed  pineal  tumor  has  so  far  been 
considered  impracticable  in  man,  owing  to  the  pronounced 
danger  to  life  (far  greater  than  in  pituitary-  surgery)  attend- 
ing such  an  operation.  Lumbar  puncture  has  at  times  proven 
serviceable  in  relieving  pressure-symptoms.  Other  palliative 
measures  comprise  the  use  of  analgesics  for  the  exacerbations 
of  pain,  and  of  various  appropriate  procedures  for  tinnitus, 
cerebellar  symptoms,  etc.  Measures  to  retard  cachexia  may 
be  indicated. 

PINEAL  INSUFFICIENCY  AND  MENTAL 
RETARDATION. 

Dana  and  Berkeley,  with  the  co-operation  of  Goddard  and 
Gornell,--^^  have  reported  numerous  therapeutic  tests  (pineal 
feeding)  in  both  children  and  the  experimental  animals,  lead- 
mg  to  the  conclusion  that  in  mental  retardation  in  children, 
administration  of  pineal  substance  is  capable  of  markedly  stim- 


ENDOCRINIC  DISORDERS  OF  THE  OVARIES.  173 

ulating  the  slug'gish  intellectual  functions.  The  preparation 
of  pineal  used  was  made  by  rubbing  up  12  fresh  bullock's 
pineals  with  sugar,  allowing  the  mixture  to  dry,  and  dividing 
it  into  100  capsules.  Each  capsule  corresponded  to  150  pounds 
of  live  bullock.  The  dose  given  was  1  capsule  a  day.  More 
recent  observations  apparently  have  failed  to  substantiate  the 
earlier  therapeutic  conception  of  these  investigators.  God- 
dard-^o  i-j^g  announced  that  later  tests  among  children  at  the 
Training  School,  Vineland,  N.  J.,  proved  wholly  negative. 

ENDOCRINIC  DISORDERS  OF  THE  OVARIES. 

The  endocrinic  functions  of  the  ovaries  are  carried  on  by 
the  corpus  luteum,  and  the  interstitial  gland,  where  present. 
As  is  well  known,  the  corpus  luteum  results  from  metamor- 
phosis of  the  collapsed  Graafian  follicle,  after  extrusion  of  the 
ovum,  the  latter  constituting  the  external  secretion  of  the 
ovary.  The  interstitial  gland  is  inconstant  in  its  distribution, 
not  only  being  absent  in  certain  animal  species,  but  varying 
in  amount  in  dififerent  individuals  of  the  sam.e  species,  and  at 
dift'erent  seasons.  It  consists  of  epithelioid  cells,  either  dis- 
seminated or  grouped  to  form  alveoli,  in  the  ovarian  stroma. 
According  to  Wallert,^^!  interstitial  cells  occur  during  preg- 
nancy in  the  human  subject. 

According  to  Leo  Loeb,2^2  g.  function  of  the  corpus  luteum 
normally  is  to  retard  ovulation,  for  where,  at  an  early  period 
,  of  the  sexual  cycle,  all  the  corpora  lutea  are  excised,  the  next 
ovulation  is  much  accelerated.  In  pregnancy  the  life  of  the 
corpus  luteum  is,  for  some  as  yet  unknown  reason,  greatly  pro- 
longed, and  ovulation  during  pregnancy  thereby  prevented. 
This  influence  of  the  corpus  luteum  on  ovulation  was  showm 
to  be  exerted  in  a  chemical  and  not  a  mechanical  way.  An- 
other function  of  the  corpus  luteum,  according  to  Loeb,  is  to 
sensitize  the  uterine  mucosa  in  order  that  a  maternal  placenta 
be  produced  upon  its  excitaJ:ion,  either  by  the  ovum  or 
mechanical  means. 

In  addition  to  the  above  "cyclical"  functions  of  the  corpus 
luteum,  the  internally  secreting  ovarian  tissues  exhibit  other 
"non-cyclical"  functions,  producing  a  favorable  trophic  influ- 
ence on  the  uterus  and  mammary  glands,  both  of  which  under- 


174  DISEASES    OF    THE    DUCTLESS    GLANDS. 

go  gradual  atrophy  upon  excision  of  the  ovaries  and  at  the 
menopause.  The  ovaries  also  exert  a  pronounced  influence  in 
the  development  of  the  secondary  sexual  characters,  the  female 
characters  being  stimulated  through  the  endocrinic  ovarian 
activity,  and  the  obtrusion  of  male  characters  simultaneously 
prevented.  Transplantation  of  ovaries  into  castrated  males 
has  been  found  capable  of  causing  enlargement  of  the  mam- 
man'  glands,  and  substituting  female  for  male  psychic 
characters. 

Whether  the  internal  secretion  inducing  female  characters 
is  produced  by  the  corpus  luteum,  by  interstitial  cells,  or  by 
both  has  not  as  3'et  been  definitely  ascertained.  The  majority 
of  investigators,  in  experimental  administrations  of  ovarian 
extracts,  found  the  corpus  luteum  inactive  or  less  active  than 
other  portions  of  the  ovary.  A  number  of  obsen'ers  have 
noticed  that  injection  of  ovarian  (or  placental)  extracts  induces 
hyperemia  of  the  vulva  and  uterus,  together  with  cellular  thick- 
ening of  the  latter.  Substances  inhibiting  the  coagulation  of 
blood  and  inducing  hyperemia,  thus  probably  playing  a  role 
in  the  production  of  hemorrhage  at  menstruation,  were  found 
by  Schickele-"*^  both  in  the  ovaries  and  in  the  uterine  mucous 
membrane. 

That  the  ovaries  must  exert  some  endocrinic  influence  even 
during  infancy  and  later  childhood  is  asserted  by  Frank,2-i-i 
on  the  ground  that  early  castration  in  animals  produces 
eunuchoid  types,  characterized  by  undeveloped  sex  organs  and 
distinct  changes  in  stature,  the  bon}^  skeleton,  and  various 
ductless  glands.  On  the  other  hand,  at  the  menopause  a 
physiological  cessation  of  ovarian  function  takes  place,  with 
resulting  atrophv  of  the  internal  and  external  genitals,  and  of 
the  mammar}-  glands,  together  with  characteristic  changes 
in  fat  and  hair  distribution  as  well  as  of  the  psychic  condition. 
An  artificial  menopause  through  castration  in  adult  life  induces 
similar  changes.  According  to  Xeumann  and  Hermann,2^5 
castration  or  .t--ray  exposure  of  the  ovaries  results  in  a  great 
increase  of  the  cholesterin  or  cholesterin  compounds  in  the 
blood. 

That  castration  directly  or  indirectly  reduces  metabolism 
and  oxygen  consumption  seems  to  have  been  shown  by  the 
experiments  of  Loewy  and  Richter,2-i6  and  by  the  more  recent 


ENDOCRINIC  DISORDERS  Ol-  THE  OVARIES.  175 

work  of  Marlin  and  H.  Bailey.-^"  The  latter  observed,  in 
combination  with  a  gain  in  weight  after  castration  in  bitches, 
a  lowering  of  metabolism  by  from  6  to  17  per  cent.  An  animal 
with  intact  thyroid  showed  a  more  marked  diminution  of 
metabolism  than  one  with  the  thyroid  removed.  The  experi- 
menters feel  that  indirect  action  has  a  bearing  on  the  reduc- 
tion of  metabolism,  and  that  the  presence  of  a  specific  stimu- 
lus from  the  ovaries  afifecting  cellular  oxidation  has  not  yet 
been  proven.  Apart  from  oxidation,  clinical  data  are  available 
to  the  effect  that  the  ovaries  may  exert  a  control  in  the  metab- 
olism of  phosphorus  and  calcium.  Bilateral  oophorectomy  ap- 
parently causes  improvement  in  osteomalacia  by  diminishing 
the  excretion  of  these  substances. 

The  active  principle  or  principles  contained  in  the  ovary 
have  not  as  yet  been  definitely  isolated.  Numerous  bodies — 
possibly  mixtures  of  principles — claimed  to  exert  more  or  less 
pronounced  hormonic  effects  have  been  obtained  by  different 
investigators  through  extraction  with  alcohol  and  other  sol- 
vents, filtration,  desiccation,  etc.,  but  since  no  two  investiga- 
tors, apparently,  have  used  precisely  the  same  methods,  no 
uniformity  of  results  has  been  secured.  Iscovesco^-is  has  pre- 
pared from  the  organ  a  number  of  what  he  terms  "lipoid"  sub- 
stances, some  of  which  were  shown  to  have  the  power,  upon 
administration,  of  stimulating  the  growth  of  the  ovaries  and 
uterus,  while  certain  others  stimulated  different  organs  such 
as  the  thyroid,  adrenals,  heart,  kidneys,  etc.  His  chief  "homo- 
stimulating"  lipoid  is  a  yellowish,  wax-like  substance,  which, 
for  experimental  and  clinical  use,  was  made  up  in  a  2  per  cent, 
solution  in  oil,  and  has  been  commercially  available  in  France. 
Herrmann249  obtained  from  the  ovary  a  similar  product, 
described  as  a  thickly  viscous,  yellowish  oil,  giving  a  decided 
cholesterin  reaction,  and  becoming  brown  when  exposed  to  the 
air,  apparently  by  taking  up  oxygen.  This  product  was  ob- 
tained both  from  the  corpus  luteum  and  the  placenta.  Seitz, 
Wintz,  and  Fingerhut^-^o  found  in  the  corpus  luteum  one  body, 
the  "luteolipoid,"  which,  when  given  subcutaneously  before 
and  during  menstruation,  diminishes  and  abbreviates  the  flow, 
and  another  body,  "lipamin,"  soluble  in  water,  and  which,  when 
injected  in  animals,  augments  the  development  of  the  reproduc- 
tive organs,  and  in  women  overcomes  amenorrhea. 


176  DISEASES    OF    THE    DUCTLESS    GLANDS. 

W.  H.  Morley.-^i  after  reviewing  the  work  of  the  above 
investigators,  notes  that  other  workers  have  often  used  indis- 
criminately an  "extract"  which  might  be  either  aqueous,  alco- 
hoHc,  or  ethereal,  or  merely  the  dried,  powdered  ovary.  In 
future  experimental  and  clinical  work,  he  considers  greater 
uniformity  of  preparation,  and  careful  specification  of  any 
product  used,  an  urgent  necessity.  In  his  own  experimental 
work  various  extracts  were  made  by  exact  chemical  methods, 
but  yielded  onty  negative  results  in  animals,  though  one  water- 
soluble  extract  seemed  to  be  temporarily  active  clinically. 
Frank  and  Rosenbloom^ss  obtained  from  the  corpus  luteum 
and  placenta  extractives  soluble  in  lipoid  solvents,  which,  when 
injected  repeatedh'  into  previously  castrated  female  rabbits, 
caused  an  enormous  hypertrophy  and  congestion  of  the  uterus, 
even  in  animals  that  had  not  yet  reached  the  age  of  puberty. 
Extracts  from  the  corpus  luteum  of  pregnant  animals  proved 
more  effective  than  those  from  non-pregnant  animals.  The 
fact  that  unfractionated  extracts  were  quantitatively  more  efifi- 
cacious  than  any  of  the  fractions  themselves  made  it  seem 
probable  to  these  investigators — as  had  already  been  suggested 
by  others — that  the  active  substance  in  the  ovaries  is  not  a 
lipoid,  but  is  merely  carried  along  by  the  lipoids. 

Lefkow^tz  and  Frank,r53  investigating  the  ferments  of  the 
ovaries,  found  trypsin,  pepsin,  lipase,  a  very  small  amount  of 
erepsin,  and  also  amylase,  the  last  of  these  being  more  abund- 
ant in  pregnant  than  non-pregnant  animals;  the  observers  do 
not  consider  these  ferments  as  bearing  on  the  source  or  nature 
of  the  active  substance  or  substances  secreted  by  the  ovary. 

That  the  phenomena  of  heat  in  animals  are  due  to  secre- 
tion of  some  substance  into  the  blood  by  the  ovaries  is  con- 
firmed by  the  experiments  of  Marshall  and  Jolly,254  w^ho  ob- 
served transitory  symptoms  of  heat  in  bitches  previously  not 
in  heat  upon  injecting  blood-serum  or  transplanting  ovaries 
from  bitches  in  heat. 

Clinical  studies  in  ovarian  organotherapy  have  convinced 
W.  P.  Graves-35  that  preparations  of  the  corpus  luteum  alone 
are  less  efficacious  than  those  of  the  whole  ovary.  He  lays 
stress  in  this  connection  on  the  part  played  by  the  interstitial 
cells  of  the  ovary  in  the  elaboration  of  the  ovarian  internal 
secretion.    These  cells,  he  deems  it  probable,  correspond  to  the 


ENDOCRINIC  DISORDERS  OF  THE  OVARIES.  177 

lutein  cells  of  the  theca  interna  of  the  atresic  follicles  or  theca 
lutein  cells  of  the  corpus  luteum,  and  are  analogous  to  the 
testicular  interstitial  cells.  Ovarian  extracts  should  comprise 
the  stroma,  to  take  advantage  of  the  atresic  follicles.  Extracts 
thus  made  from  the  ovaries  of  pregnant  animals,  with  exclu- 
sion of  the  corpora  lutea,  clinically  proved  highly  efficacious 
therapeutically  in  his  hands.  Extracts  from  the  corpora  lutea 
of  pregnancy,  on  the  other  hand,  proved  too  toxic  for  practical 
use. 

Sajous,  Sr.,256  has  emphasized  the  resemblance  of  the 
ovarian  interstitial  cells  to  the  cells  of  the  suprarenal  cortex 
previously  pointed  out  by  Mulon,  Wallart,  and  others,  and 
attributes  the  production  of  the  internal  secretion  of  the  ovaries 
mainly  to  the  dynamism  of  adrenal  rests  in  the  interstitial 
org-an  and  corpora  lutea. 

ENDOCRINIC  OVARIAN  INSUFFICIENCY. 

The  effects  of  insufficiency  of  the  Internal  secretion  of  the 
ovaries  vary  markedly  according  to  the  period  of  life  at  which 
the  deficiency  arises,  as  well  as  various  other  factors.  There 
is  still  much  discussion  as  to  what  symptoms  are  and  what 
are  not  due  to  this  form  of  disturbance. 

Where  the  insufficiency  arises  during  the  developmental 
period,  certain  characteristic  abnormalities  of  growth  may  be 
noted,  the  extremities,  e.g.,  becoming  unusually  elongated  in 
relation  to  the  length  of  the  trunk,  the  sacrum  being  flattened 
instead  of  curved,  and  the  pelvic  outlet  remaining  narrow,  in- 
stead of  expanding,  as  in  the  normal  female.  The  distribution 
of  fat  and  of  the  hairy  covering  fails  to  exhibit  in  full  degree 
the  female  characteristics,  tending  rather  toward  a  eunuchoid 
or  male  condition,  while  the  genital  organs  remain  small  and 
infantile.  In  these  or  adult  cases  there  also  frequently  exist 
nervous  and  vasomotor  symptoms,  such  as  unusual  general  ex- 
citability or  nervous  slug-gishness,  flushes,  sweats,  and  dizzy 
sensations.  Altered  function  of  the  genital  tract  shows  itself, 
under  such  circumstances,  in  the  form  of  dysmenorrhea  with  a 
scanty,  irreg"ular  flow,  or  amenorrhea,  coupled  with  sterility. 
As  Frank2-5"  remarks,  secondary  hypofunction  of  the  ovaries 
may  Qccur  as  a  result  of  thyroid  disease,  as  in  myxedema  or 

12 


178  DISEASES    OF   THE   DUCTLESS    GLANDS. 

exophthalmic  goiter;  from  pituitary  disease,  as  in  the  second 
stage  of  acromegaly  and  in  the  dystrophia  adiposogenitalis,  or 
in  association  with  insufficiency  of  the  adrenal  medulla,  as  in 
Addison's  disease.  Such  secondary  hypofunction  is  often  pre- 
ceded by  a  preliminary  period  of  ovarian  hyperactivity. 

The  well-known  symptomatic  and  other  manifestations  of 
the  natural  menopause  constitute,  in  a  sense,  the  type  of  the 
conditions  resulting  from  cessation  of  the  functions  of  the 
ovaries  at  any  time  after  the  close  of  the  developmental  period. 
Especially  noteworthy  are  the  accumulation  of  adipose  tissue 
and  the  vasomotor  disturbances.  According  to  Graves,-^^ 
the  "ablation  symptoms"  following  extirpation  of  the  uterus 
and  adnexa  by  improved  surgical  technic  are  now  much  less 
distressing  than  formerly,  when  "disabling  and  discouraging 
postoperative  complications"  were  of  common  occurrence. 
The  only  specifically  characteristic  S3^mptom,  according  to  this 
observer,  is  hot  flashes,  though  frequently  associated  with  it, 
or  sometimes  occurring  independently,  are  sensations  of  alter- 
nate heat  and  cold,  palpitation,  feelings  of  anxiety,  dizziness, 
and  sleeplessness.  The  majority  of  patients,  states  Graves, 
suffer  comparatively  slight  inconvenience  from  removal  of  the 
ovaries,  and  many  of  them  none  at  all — a  circumstance  which 
he  ascribes  to  "the  subordinate  part  played  by  the  ovary  dur- 
ing maturity  in  the  group  of  ductless  glands."  Presenting  a 
table  of  statistics,  this  author  calls  attention  to  the  fact  that 
where,  in  performing  hysterectomy,  one  or  both  ovaries  are 
left  in  situ,  the  subsequent  incidence  of  hot  flashes  is  no  less- 
— 81  per  cent. — than  where  both  ovaries  have  been  removed. 
This  he  ascribes  to  a  disturbance  of  the  physiological  relation- 
ship of  the  uterus  and  ovaries,  a  condition  of  ovarian  "dys- 
function" being  the  result,  which  often  can  be  corrected  only 
by  subsequent  removal  of  the  ovaries  themselves.  Later,  how- 
ever, he  states  that  upon  removing  ovaries  retained  at  a  pre- 
vious hysterectomy  he  had  found  them  in  every  instance 
"densely  -adherent,  degenerated,  and  cystic."  Such  findings, 
we  may  note,  suggest  that  the  hot  flashes  he  supposes  due  to 
ovarian  "dysfunction"  result  merely  from  destruction  of  the 
ovaries,  and  do  not  support  the  view  that  cessation  of  ovarian 
interstitial  secretion  per  se  is  not  responsible  for  the  surgical 
menopause  symptoms.     Graves  also  remarks  that  hot  flashes 


ENDOCRINIC  DISORDERS  OF  THE  OVARIES.  179 

were  reported  after  removal  of  the  ovaries  by  many  patients 
who  had  already  passed  the  menopause.  This  would  tend  to 
show,  as  he  states,  that  the  ovary  retains  its  influence  as  a 
secretory  organ  long  after  ovulation  ceases. 

The  nervous  and  mental  disturbances  following-  surgical 
castration  in  women  have  been  emphasized  by  Alfred  Gor- 
don,2-"»9  who  finds  that  the  psychic  manifestations  may  belong 
to  any  of  the  varieties  of  psychoneuroses,  but  in  their  ensemble 
do  not  constitute  any  of  the  classical  forms  of  psychasthenia. 
The  symptoms  generally  observed  are  restlessness ;  difficulty 
of  self-control;  dissatisfaction  with  all  and  everything;  diffi- 
culty of  finding  contentment  in^s one's  own  efforts;  want  of 
interest  in  all  absorbing  subjects  and  objects;  indifference, 
indolence,  and  pessimism ;  sometimes  outbreaks  of  anger,  with 
a  tendency  to  attack.  Along  with  these  occurred  at  times  in- 
somnia, functional  gastro-intestinal  disturbances,  headache, 
vague  pains  or  paresthesias,  and  occasionally  glycosuria  and 
a  tendency  to  obesity.  Some  of  these  patients  became  intol- 
erable to  live  with,  and  had  to  be  isolated.  A  remarkable  per- 
sistence of  the  morbid  phenomena  was  also  noticed,  some  pa- 
tients showing  the  condition  unaltered  after  ten  years. 

Many  of  the  nervous  phenomena  just  noted  are  suggestive 
of  hyperthyroidia,  and,  as  pointed  out  by  Bandler,^^^  thyroid 
disturbances,  in  particular  a  marked  instability  of  thyroid  func- 
tion or  relative  hyperthyroidia,  not  infrequently  accompany 
the  normal  climacteric.  Among  other  glandular  activities 
which  may  be  affected,  Bandler  refers  to  an  excessive  function- 
ing of  the  anterior  lobe  of  the  pituitary,  ascribed  to  removal 
of  "inhibition"  by  the  ovary.  Overactivity  or  insufficiency  of 
the  posterior  pituitary  lobe  or  of  the  adrenals  are  also  recog- 
nized as  possible  accompaniments,  with  corresponding  metab- 
olic and  other  symptoms.  A  severe  menopause,  according  to 
this  author,  speaks  in  general  for  a  poorly  balanced  endocrine 
system. 

The  relationship  of  the  ovaries  to  disorders  of  menstruation 
has  been  studied,  among  others,  by  E.  Novak. ^61  While  be- 
lieving it  a  demonstrated  fact  that  the  corpus  luteum  is  the 
cause  of  normal  menstruation,  Novak,  in  careful  histological 
studies  of  the  ovaries  from  102  cases,  was  unable  to  find  any 
direct  relation  between  the  degree  of  luetin  development  in 


ISO  DISEASES    OF    THE    DUCTLESS    GLANDS. 

the  ovary  and  the  clinical  intensity  of  the  menstrual  flow. 
Involvement  of  the  ovary  in  inflammatory  disease  has,  how- 
ever, been  considered  by  Hitschmann  and  Adler^QS  g.  cause 
of  excessive  menstruation.  The  amenorrhea  of  anemia, 
phthisis,  and  other  debilitating  conditions  is  possibly  due, 
according  to  Novak,  to  an  inhibitory  effect  on  the  corpus 
luteum,  or  more  probably,  to  failure  of  ovulation  itself.  This 
author  also  regards  fibrocystic  disease  of  the  ovaries  as  an  im- 
portant index  of  ovarian  hyperemia  and  hyperfunction,  with 
excessive  menstruation  as  the  most  frequent  clinical  symptom. 
Late  menstruation,  hypoplasia  of  the  uterus  and  adnexa, 
and  poorly  developed  secon^iary  sex  characteristics  may  con- 
stitute evidence,  as  Bandler^ss  states,  of  either  a  primary  in- 
volvement of  the  ovaries  and  genital  tract,  or  of  a  secondary 
influence  exerted  upon  them  by  the  thyroid,  hypophysis,  ad- 
renals, thymus,  or  other  glands.  Hypoplastic  ovaries,  accord- 
ing to  this  author,  may  indicate  a  persistent  thymus.  The 
amenorrhea  of  lactation,  ascribed  to  inhibition  of  the  corpus 
luteum  by  a  hormone  from  the  actively  functionating  mam- 
mary glands,  may,  if  excessively  prolonged,  eventuate  in  an 
atrophy  of  the  uterus  and  inhibition  of  ovarian  function  which 
can  generally  be  overcome  with  ovarian  extract,  thyroid,  iron, 
and  arsenic.  Bandler  writes  also  of  a  decided  atrophy  of  the 
uterus  which  occasionally  follows  a  too  thorough  curettage, 
and  which  he  ascribes  to  removal  of  the  stimulating  effect  of 
the  endometrium,  when  still  in  situ,  on  the  ovary ;  this  stimulus 
being  lost,  the  resulting  ovarian  depression  reacts  on  the 
uterus.  In  young  women  with  a  more  or  less  mild  grade  of 
the  adiposogenital  syndrome  there  occurs,  along  with  pro- 
gressively increasing  obesity,  a  diminution  of  the  ovarian 
function  and  of  menstruation.  An  atrophy  of  the  uterus  and 
ovaries  takes  place  which  in  many  cases  no  method  of  treat- 
ment will  overcome.  Again,  in  the  second  stage  of  acromegaly, 
with  the  accompanying  depression  of  ovarian  and  uterine  func- 
tion, a  pronounced  diminution  of  menstruation  is  observed. 

TREATMENT. 

There  still  exist  marked  differences  of  opinion  as  to  the 
actual  value  of  ovarian  extracts.  This  is  probably  due  in  part 
to  the  variety  of  methods  of  preparation,  some  of  the  extracts 


ENDOCRINIC  DISORDERS  OF  THE  OVARIES.  181 

used  having  no  doubt  been  actually  devoid  of  physiological 
activity.  Graves,  as  already  mentioned,  has  pointed  out  that 
ovarian  extract,  for  its  best  effectiveness,  should  include  the 
interstitial  cells,  or  at  least  their  product.  Bucura-*^^  recom- 
mends that  in  the  natural  or  artificial  menopause  ovarian  ex- 
tract be  given  in  increasing  dosage  until  all  the  symptoms 
complained  of  disappear,  i.e.,  for  a  period  of  one  to  three  years, 
if  necessary.  At  first  he  administers  the  extract  for  a  period  of 
three  to  eight  weeks,  next  discontinues  it  for  one  week,  then 
resumes  it,  etc.,  gradually  diminis'hing  the  period  of  medica- 
tion until  eventually  the  remedy  is  taken  but  one  week  m  each 
month.  For  the  relief  of  the  hot  flushes  or  psychoneurotic 
manifestations  of  the  menopause,  or  of  neurasthenic  symp- 
toms during  menstrual  life,  ovarian  therapy  has  found  favor  in 
various  quarters,  thoug'h  a  few  continue  to  deny  it  any  degree 
of  utility.  In  all  cases  of  diminishing  menstruation,  says  Hand- 
ler, ovarian  extract  is  indicated.  In  late,  menstruation  and  an 
infantile,  hypoplastic  condition  of  the  generative  organs,  the 
initially  causative  gland  should  be  ascertained  and  due  organic 
treatment,  e.g.,  thyroid  or  pituitary  preparations  given,  along 
with  ovarian  extract  and  corpus  luteum.  As  Novak  found  the  cor- 
pus luteum  mature  during  that  portion  of  the  menstrual  cycle 
in  which  the  endometrium  exhibits  the  premenstrual  hyper- 
trophy, special  administration  of  corpus  luteum  extract  is  par- 
ticularly advisable  in  amenorrhea  or  oligomenorrhea.  Other 
indications  which  have  been  given  for  corpus  luteum  or  ovarian 
therapy  include  sterility  not  due  to  pyogenic  infection  or 
mechanical  obstruction ;  insufficient  compensatory  activity  of 
a  remaining  ovary  after  its  fellow  has  been  removed ;  repeated 
abortions  not  due  to  disease  or  mechanical  factors ;  hyper- 
emesis  in  the  early  months  of  pregnancy.  Iscovesco-*^-^  used 
a  ''lipoid"  prepared  from  the  ovary  with  good  results  in  a  num- 
ber of  cases  of  amenorrhea,  dysmenorrhea,  disturbances  due  to 
ovarian  insufficiency  or  the  menopause,  chlorosis,  and  senile 
debility.  A  2  per  cent,  oily  solution  of  the  lipoid  was  injected 
deeply  into  the  gluteal  muscles  in  the  dose  of  1  mil  (15  m.) 
daily,  or  4  to  6  pills,  each  containing-  0.02  gram  (^  gT.)  of  the 
lipoid,  were  given  by  mouth. 

Transplantation   of  ovarian  tissue  has  in  many  instances 
been  resorted  to  in  order  to  afford  the  system  a  continuous 


182  DISEASES    OF   THE    DUCTLESS    GLANDS. 

supply  of  ovarian  product  where  removal  of  the  ovaries  is 
necessitated  by  disease  or  the  ovaries  have  for  any  other 
reason  become  insufficient.  According  to  Graves,  who  trans- 
planted sections  of  healthy  ovarian  tissue  in  the  rectus  muscle 
in  cases  in  which  the  OA'aries  had  to  be  removed  for  pelvic 
disease,  such  transplantation  has  no  marked  influence  on  the 
surgical  menopause  symptoms.  Lydston's  work, 2*56  however, 
has  shown  that  ovarian  implantation  is  by  no  means  devoid  of 
physiological  effects,  at  least  in  some  cases.  In  one  of  his 
cases,  a  woman  of  59  years,  an  ovar}^  from  a  girl  of  16,  re- 
moved twelve  hours  after  death  from  skull  fracture,  was  im- 
planted eleven  hours  later  into  the  left  labium  majus.  The 
patient's  hot  flushes,  sense  of  exhaustion,  somnolence,  stiffness 
of  the  knees,  and  long-standing  bilateral  sciatica  disappeared 
permanently  soon  after  the  transplantation.  Five  months  after 
the  procedure  the  implanted  ovary,  though  diminished  in  size, 
could  still  be  distinctly  felt.  In  a  second  case,  in  a  girl  of  17 
with  dementia  prsecox,  ovarian  implantation  led  to  marked 
improvement  in  the  mental  and  physical  condition.  A  num- 
ber of  other  observers  have  had  experiences  with  ovarian  trans- 
plantation which  have  seemed  to  indicate  physiological  value 
on  the  part  of  this  procedure.  Some,  however,  have  had  what 
they  consider  disappointing  results,  and  emphasize  that  a 
great  problem  remaining  to  be  solved  in  this  connection  is 
that  of  overcoming  the  resistance  of  the  body  to  grafts  from 
other  individuals,  whereby  such  grafts  often  become  absorbed 
within  a  relatively  short  time  and  fail  to  gain  a  foothold  in 
the  tissues  of  the  new  host. 

ENDOCRINIC  OVARIAN  OVERACTIVITY. 

Menorrhagia  and  metrorrhagia  may  at  times  be  considered 
manifestations  of  such  a  state.  As  Frank-^"  points  out,  the 
condition,  when  primary,  is,  as  a  rule,  limited  to  the  period  of 
sexual  maturity,  though  apt  to  be  most  severe  toward  the  be- 
ginning and  the  termination  of  the  period,  viz.,  at  the  time 
of  pubert}^  and  in  the  preclimacteric.  Hyperplasia  of  the 
uterine  mucosa  is  a  frequent  accompaniment,  and  the  uterine 
muscle  itself  may  be  thickened.  Some  evidence,  according  to 
Frank,  is  at  hand  indicating  that  fibroid  tumors  of  the  uterus 
are  caused  by  such  a  functional  hyperplasia.    That  the  second- 


ENDOCRINIC  DISORDERS  OF  THE  OVARIES.  183 

ary  sex  characters  may  be  in  some  degree  modified  l>y  unusual 
activity  of  the  ovarian  interstitial  tissue  is  suggested  by  Riddle's 
observation  that  doves  can  be  rendered  "overfeminine"  in  their 
behavior  and  characteristics  by  injections  of  ovarian  material. 
Bandler-'^^  recognizes  a  form  of  endometrial  overgrowth  and 
menorrhagia  resulting  from  ovarian  hyperactivity. 

Alarked  precocity  of  genital  development  is  occasionally 
met  with  in  the  female  sex,  though  more  rarely  than  in  male 
children.  Most  of  these  cases  are  characterized  particularly  by 
precocious  menstruation,  which  may  occur  even  before  the  end 
of  the  first  year  of  life.  With  it  may  be  associated  premature 
mammary  enlargement,  abnormal  size  of  the  external  geni- 
talia, a  female  type  of  hirsuties,  premature  change  of  teeth, 
and  early  epiphyseal  closure.  Excessive  development  of  the 
body  as  a  whole  may  also  be  observed.  In  Riedel's  case,  men- 
struation was  observed  in  a  6-year  old  child,  and  the  size  of 
the  uterus  corresponded  with  that  of  a  normal  child  of  17.  At 
operation  an  ovarian  sarcoma  was  found,  upon  removal  of 
which  menstruation  ceased.  While  in  this  case  the  ovarian 
overactivity  was  primar}^,  such  overactivity  may  in  other  in- 
stances be  secondary  to  hormonic  influences  from  other  duct- 
less glands,  as  in  exophthalmic  goiter,  acromegaly,  pineal 
disease,  etc. 

TREATMENT. 

Careful  study  to  ascertain  the  cause  of  the  excessive  ovarian 
activity,  and  in  particular  whether  it  is  primary  or  secondary, 
is  obviously  a  necessity.  X-ray  treatment  is  probably  capable, 
in  suitable  dosage,  of  curbing  the  condition,  though  experience 
thus  far  has  led  to  the  impression  that  it  is  more  difficult  to 
arrest  the  function  of  the  ovarian  interstitial  cells  with  the 
rays  than  to  destroy  the  external  secretory  function  of  the 
ovaries,  viz.,  ovulation.  According  to  Bandler,269  thymus  ex- 
tract is  effectual  in  the  persistent  menorrhagia  of  young-  girls 
and  in  menorrhagia  or  metrorrhagia  following  a  vaginal  opera- 
tion for  uterine  prolapse.  Where  tumors  responsible  for 
ovarian  hyperactivity  exist,  either  in  the  ovaries  themselves 
or  in  other  organs,  their  surgical  removal,  where  practicable, 
will  in  some  instances  be  indicated ;  in  others,  .r-ray  treatment 
may  suffice. 


184  DISEASES    OF    THE    DUCTLESS    GLANDS. 

ENDOCRINIC  DISORDERS  OF  THE 

TESTICLES. 

The  internal  secretion  of  these  organs  is  now  generally  held 
to  arise  in  the  interstitial  cells  of  Leydig — strands  of  poly- 
hedral epithelial  cells,  of  a  yellowish  color,  and  frequently 
containing  "cr}'stalloid  bodies,"  situated  in  the  rather  loose 
connective  tissue  of  the  testicles  which  separates  the  lobules 
of  the  externally  secreting  or  seminiferous  tissues.  Bouin  and 
Ancel,-"*^  experimentallv  ligating  the  vasa  deferentia  in  ani- 
mals, found  that  while  the  seminiferous  tubules  atrophied,  the 
interstitial  cells  remained  unaffected,  and  urged  that  the  activ- 
ity of  these  cells  was  responsible  for  the  development  of  the 
secondary  sexual  characteristics  in  the  male.  The  same  in- 
vestigators later  ascertained  that  subcutaneous  injections  of 
extracts  of  the  interstitial  tissue  reduced  the  eft"ects  of  castra- 
tion, and  that  the  interstitial  cells  develop  synchronously  with 
the  first  appearance  of  spermatogenesis.  The  conception  of 
the  interstitial  cells  as  the  source  of  the  secondary-  sex  char- 
acteristics was  confirmed  by  Shattock  and  Seligmann,^^!  who 
observed  that  occlusion  of  the  vasa  deferentia  in  sheep,  with 
the  subsequent  atrophy  of  the  seminiferous  tissues,  does  not 
prevent  development  of  these  male  characteristics.  Foges-'^^ 
found  that  transplanted  testes  had  the  same  influence  in  de- 
veloping secondary  sexual  characteristics  as  had  normally  sit- 
uated testes,  thus  showing  that  spermatogenesis  is  not  a  pre- 
requisite to  a  male  type  of  development. 

Experimental  work  by  Allen  J.  Smith  and  AV.  J.  Crockery's 
has  shown  that  mere  injections  of  testicular  extract  are  capable 
at  times  of  developing  male  secondar}^  sexual  characteristics 
in  the  opposite  sex,  even  where  previous  removal  of  the  ovaries 
has  not  been  performed.  Thus,  in  their  experiments,  injection 
of  a  salt  solution  extract  of  cock's  testes  into  hens  usually 
caused  an  increase  in  size  and  brighter  coloration  of  the  comb 
and  wattles ;  greater  brilliancy  of  the  neck  feathers ;  in  one 
instance  a  distinct  growth  of  spurs;  diminished  egg  produc- 
tion ;  combativeness,  and  even,  in  several  cases,  a  tendency  to 
cover  other  hens  after  the  manner  of  the  cock.  According  to 
some,  an  influence  of  the  testicular  extract  on  trophic  ner^'es 
may  be  implicated  where  actual  tissue  modifications  occur  as  a 


ENDOCRINIC  DISORDERS  OF  THE  TESTICLES.  185 

result  of  its  effects.  A  hormonic  action  is,  however,  even  more 
clearly  recog-nized.  Launois  and  Roy-'^"^  state  their  belief  that 
one  of  the  functions  of  the  generative  glands  is,  in  common 
with  certain  other  ductless  g-lands,  to  direct,  throug-h  the 
agency  of  the  nervous  system,  the  nutrition  of  certain  tissues, 
especially  those  of  mesodermal  source,  viz.,  connective  tissue, 
cartilag'e,  and  bone.  The  effects  of  castration  in  delaying  the 
termination  of  the  process  of  endochondral  bone  production, 
abnoi-mal  length  of  the  long  bones  resulting,  constitute  evi- 
dence of  an  important  controlling  power  of  the  testes  over 
osseous  metabolism. 

A  distinct  stimulating  influence  of  testicular  extracts  on 
the  neuromuscular  mechanism  has  been  proved  to  exist  by 
Zoth^'i'S  and  others.  Ergographic  tests  showed  that  extract 
injections  materially  diminish  the  muscular  and  nervous 
fatigue  which  follows  physical  work.  Subjective  fatigue  sen- 
sations are  likewise  reduced. 

The  most  convincing  proof  of  the  essential  influence  of  the 
interstitial  testicular  tissue  in  establishing  and  maintaining  the 
secondary  sex  characteristics  is  afforded  by  the  work  of 
Steinach,2'''6  who,  upon  transplanting  testes  in  very  young 
animals  from  their  normal  position  to  other  situations,  saw 
all  the  secondary  sex  characteristics  develop  at  the  usual  time, 
with  full  sexual  desire  and  potency.  Upon  examination  of  the 
transplanted  glands,  the  spermatogenetic  structures  were 
found  absent,  the  interstitial  tissues,  however,  being  increased 
in  amount.  In  further  experiments,  Steinach  castrated  young 
male  rats  and  guinea-pigs  and  transplanted  an  ovary  under  the 
skin  or  in  the  peritoneal  cavity.  In  such  animals  the  male 
characteristics  failed  to  develop,  and  the  male  genital  organs 
remained  infantile.  Female  secondary  sex  characteristics  deve- 
loped to  such  an  extent  that  the  animals  were  "completely  femi- 
nized," and  were  sought  by  the  males  as  though  actually  females. 

The  precise  nature  of  the  active  substance  or  substances  in 
testicular  extract  has  not  as  yet  been  demonstrated.  W.  E. 
Dixon^'*'"  found  it  to  contain  a  large  percentage  of  nucleopro- 
teid.  He  states  that  it  also  contains  a  number  of  extractives, 
and  among  these  spermine,  held  by  Poehl  the  chief  active  con- 
stituent. Lecithin  and  cholesterin  were  also  noted,  together 
with  inorganic  salts.     The  significance  of  the  nucleoproteids 


186  DISEASES    OF    THE    DUCTLESS    GLANDS. 

in  the  economy  is  unknown,  thoug^h,  according  to  some,  they 
are  the  source  of  the  beneficial  effects  obtained  from  testicular 
preparations.  Spermine,  an  organic  base  with  the  empirical 
formula  C5H14N2,  has  been  held  by  Poehl  and  others  to  have 
the  power  to  accelerate  oxidation  of  oxidizable  bodies,  or  act 
as  an  oxygen  carrier.  This  has  led  Sajous,  Sr.,  to  assimilate 
spermine  to  the  oxygen-carr}ang  adrenal  principle,  with  which 
it  corresponds  in  many  of  its  chemical  properties.  According 
to  Pantchenko,  spermine  is  capable,  acting  catalytically,  of  in- 
creasing the  oxidizing  power  of  the  blood  and  simultaneously 
activate  intraorganic  oxidation  processes  where  these  are  weak- 
ened. The  fact,  however,  that  spermine  has  been  shown  to 
occur  in  situations  other  than  the  testicles — in  fact,  according 
to  Dixon,  it  exists  constantly  in  all  body  tissues — tends  to 
diminish  the  significance  of  spermine  as  a  specific  testicular 
product,  and  to  sustain  the  views  of  Sajous,  Sr.  While  present 
in  largest  amount  in  the  testes  and  in  ner^^e-tissue,  spermine 
has  been  found  increased  in  the  blood  in  leukemia  and  nervous 
diseases ;  it  was  also  discovered  early  by  Leyden  in  the  sputum 
of  asthmatics. 

..    ENDOCRINIC    TESTICULAR    INSUFFICIENCY.    . 

Castration  in  childhood  prevents  the  series  of  anatomic  and 
functional  changes  which  normally  characterize  puberty.  The 
skin  tends  to  remain  soft  and  white ;  the  beard  does  not  grow ; 
the  larynx  fails  to  enlarge,  and  the  voice  remains  high-pitched. 
The  muscles  do  not  develop  to  the  extent  usual  in  a  vigorous 
male,  while  the  long  bones  of  the  extremities  tend  to  become 
longer  than  normal,  and  the  stature  of  the  individual  exceeds 
that  which  would  otherwise  have  resulted.  The  reproductive 
organs  as  a  whole  tend  to  undergo  atrophy,  but  the  mammary 
glands  are  likely  to  grow  larger  than  those  of  the  normal  male. 
In  general,  there  is  a  tendency  to  abnormal  fat  deposition,  with 
distribution  suggesting  the  female  type.  IMentally,  these  sub- 
jects are  unusually  even-tempered,  as  compared  to  other  males, 
but  they  are  distinctly  lacking  in  initiative,  are  apt  to  be 
timorous,  submissive,  and  cowardly,  and  may  be  in  some  de- 
gree intellectually  blunted.  Castration  at  any  time  before 
completion  of  sexual  development  regularly  causes  impotence 
and  loss  of  sexual  desire. 


ENDOCRINIC  U1S01>^13EKS  UF  THE  TESTICLES.  187 

A  eunuchoid  state  alone  results,  on  the  other  hand,  where 
castration  occurs  only  after  completion  of  sex  development, 
or  where  the  removal  of  the  internally  secreting-  testicular  tis- 
sue has  been  only  partial.  While  tendencies  as  regards  fat 
deposition,  deficient  hirsuties,  smooth  skin,  and  mammary  de- 
velopment, similar  to  those  in  complete  eunuchism,  may  be 
noted,  the  change  of  voice  will  generally  have  already  taken 
place,  together  with  the  ossification  of  the  epiphyses,  and  con- 
sequent arrest  of  the  stature  at  a  normal  limit.  Sexually,  where 
castration  occurs  after  puberty,  desire  and  potency  may  remain 
little  affected  for  some  time,  emissions  occurring  which  re- 
semble normal  semen  in  spite  of  the  absence  of  spermatozoa 
therein.  This  fact  is  ascribed  to  the  persistence,  even  after 
castration,  of  the  various  genito-spinal,  cerebral,  and  sympa- 
thetic nervous  mechanisms  related  to  the  reproductive  organs, 
these  nervous  mechanisms  having  already  become  fully  de- 
veloped before  the  castration.  The  possibility  of  a  vicarious 
action  of  other  hormones  in  such  cases  has  also  been  given  con- 
sideration, Lydston,  e.g.,  suggesting  that  there  is  a  prostatic 
hormone  which  functionates  vicariously  until  the  prostate  itself 
atrophies  as  a  result  of  the  castration.  The  penis  and  other 
genital  organs  may  also  show  evidences  of  atrophy  from  ces- 
sation of  the  testicular  internal  secretion. 

The  causes  of  such  endocrine  testicular  insufficiency  com- 
prise, in  particular,  traumatic  injuries  of  these  organs  at  any 
period  of  life,  diseased  conditions  of  the  testicles,  such  as  may 
be  due  to  gonococcal,  syphilitic,  or  tuberculous  involvement,  or 
occur  as  a  complication  of  mumps,  and  a  disturbed  nutritive 
condition  of  the  testicles  due  primarily  to  disease  of  some 
other  ductless  gland,  as  in  the  dystrophia  adiposogenitalis. 

TREATMENT. 

The  chief  therapeutic  measure  in  interstitial  testicular  in- 
sufficiency consists  in  supplying  the  product  or  products  which 
the  organism  lacks,  either  by  the  use  of  extracts  or,  far  prefer- 
ably, by  testicular  transplantation.  As  regards  spermine,  most 
attention  seems  to  have  been  attracted  to  its  apparent  tonic 
effect  on  the  circulation  and  an  asserted  general  improvement 
of  tissue  oxidation;  little  that  is  definite  has  been  recorded 
tending  to  demonstrate  direct  usefulness  of  this  product  in 


188  DISEASES    OF    THE    DUCTLESS    GLANDS. 

counteracting  interstitial  deficiency  of  the  testes.  There  seems 
little  doubt  that  a  complete  extract  of  these  organs  is  capable 
of  ser^nng  much  more  satisfactorily.  While  one  may  safely 
disregard  sweeping  dicta  which  would  establish  testicular  ex- 
tract as  a  general  panacea  for  neurasthenia  and  other  forms  of 
systemic  debility,  little  doubt  can  further  prevail  that  such  an 
extract  is  frequently  capable  of  limiting,  in  some  degree  at 
least,  the  prejudicial  effects  of  castration.  Where  such  castra- 
tion has  occurred  before  puberty,  the  use  of  extracts  is  doubt- 
less totally  insufficient  to  promote  development  of  the  missing 
secondar}^  characteristics.  W^here  the  loss  of  the  interstitial 
testicular  secretion  has  occurred  only  after  puberty,  however, 
testicular  organotherapy  frequently  yields  results  such  as  ren- 
der its  use  well  worth  while.  Although  a  manifest  influence  on 
the  secondary  sex  characteristics  is  hardly  to  be  expected,  very 
appreciable  results  may  be  obtained  in  the  removal  of  the  cir- 
culatory sluggishness,  lack  of  mental  alertness,  and  impair- 
ment of  certain  reflex  functions,  from  which  the  castrated 
habitually  suffer.  According  to  the  experimental  demonstra- 
tions of  hoewj  and  Richter,  the  generatiA^e  glands,  whether 
male  or  female,  exert  a  distinct  influence  in  stimulating  metab- 
olism, or  at  least,  oxidation.  The  deficient  general  metabolic 
activity  attending  castration  is  probably  the  most  easily  re- 
moved by  organotherapy  of  all  the  effects  of  cessation  of  the 
interstitial  secretory  function. 

^^"here  organic  extracts  can  alone  be  employed,  combina- 
tion of  certain  extracts  other  than  testicular  with  the  latter 
seems  to  be  advantageous.  Especially  does  this  apply  in  the 
case  of  extracts  of  the  anterior  lobe  of  the  pituitar}^  and  of  the 
thyroid  gland.  Some  evidence  of  the  influence  of  anterior  lobe 
extract  on  the  male  reproductive  organs  is  afforded  b}^  the  ob- 
servations of  Stellwagen.2"8  Th^^roid  substance  in  moderate 
dosage  seems  of  advantage  in  assisting  to  overcome  the  slug- 
gish metabolism  and  adipose  tendency  which  result  from  cas- 
tration, whether  complete  or  incomplete.  Possibly  an  extract 
of  the  adrenal  cortex  may  likewise  prove  of  some  ser\nce. 

The  superiority  in  the  results  of  testicular  transplantation 
over  those  of  organotherapy  appear  to  be  so  pronounced  that 
the  former  is  to  be  strongly  advised  when  practicable.  In  the 
clinical  field,  important  pioneer  work  has  been  accomplished 


ENDOCUINIC  DISORDERS  OF  THE  TESTICLES.  189 

in  the  United  States,  chiefly  l)y  Lydston.^"^  Lespinasse  had 
already  in  1913  reported  a  case  of  impotence  relieved  by  slices 
of  testis  1  millimeter  thick  transferred  from  a  living-  subject  to 
another  who  had  been  castrated.  The  implantations  were 
made  in  the  scrotum  and  rectus  muscle.  In  four  days  sexual 
desire  and  erectile  power  were  restored,  and  had  persisted  two 
years  when  the  patient  was  last  seen.  Lydston^so  h^s  reported 
successful  performance  of  a  number  of  procedures  never  pre- 
viously carried  out,  viz.,  the  first  implantation  of  an  entire 
human  testis  for  therapeutic  or  experimental  purposes  ;  implan- 
tation of  human  sex  glands — ovary  or  testis — taken  from  the 
dead  body ;  demonstration  of  the  survival  of,  and  acquirement 
of  new  circulation  by,  implanted  human  sex  g-lands ;  implanta- 
tion of  sex  glands  in  dementia  prsecox,  senility,  and  feminism 
due  to  aberrations  of  testicular  structure  and  function.  His 
experiences  appear  to  him  as  probably  refuting  the  belief  that 
glands  from  alien  sources,  i.e.^  from  other  individuals,  cannot 
survive,  at  least  for  a  considerable  period,  after  implantation. 
In  some  cases,  indeed,  permanent  survival  of  alien  glands 
seemed  probable.  Glands  taken  from  a  living  subject,  while 
most  desirable,  are  rarely  obtainable,  and,  according  to  Lyds- 
ton,  are  not  more  viable  than  those  taken  from  dead  subjects; 
nothing  is  lost  by  ordinary  refrigeration  for  twenty-four  to 
forty-eight  hours  before  implantation.  Portions  of  glands, 
when  implanted,  are  to  a  certain  degree  serviceable,  according 
to  conditions  and  dose.  The  benefits  of  implantation  probably 
accrue  irrespective  of  the  site  of  implantation.  The  procedure 
was  found  to  have  a  very  useful  field)  in  the  treatment  of  im- 
potence, and  it  is  believed  implantation,  with  or  without  anas- 
tomosis with  the  vas  deferens,  may  have  a  certain  range  of  use- 
fulness in  sterility.  Sexual  inversions  or  perversions,  certain 
cases  of  cryptorchidism  and  imperfect  testicular  development, 
or  atrophy  from  disease,  are  deemed  a  promising-  field  for  the 
procedure.  Stress  is  also  laid  on  the  general  physiologic  effi- 
cienc}^,  and  hence  individual  and  social  efficiency,  accruing 
from  testicular  implantation.  At  least  one  of  Lydston's  cases 
plainly  shows  a  favorable  influence  of  testicular  implantation 
in  leading  to  the  establishment  of  male  secondary  sex  char- 
acteristics in  spite  of  complete  destruction  of  the  testicles  be- 
fore puberty. 


190  DISEASES   OF   THE   DUCTLESS   GLANDS. 

In  a  case  of  grafting  reported  by  R.  T.  Morris,28i  3  wedge- 
shaped  segments  of  testicle,  each  about  3  mm.  in  thickness, 
were  implanted,  respectively,  beneath  the  sheaths  of  the  left 
and  right  rectus  abdominis  muscles  and  into  the  scrotum  of  a 
man  aged  27  who  had  lost  both  organs  as  a  result  of  orchitis 
complicating  mumps  at  the  age  of  13.  Although  the  tissue 
implanted  in  the  scrotum  gradually  diminished  in  size,  the 
remaining  vestige  of  atrophied  testicle,  along  with  the  epi- 
didymis and  spermatic  cord,  showed  a  synchronous  consider- 
able enlargement.  Distinct  evidences  of  stimulation  of  the 
sexual  function  were  observed,  but  the  patient's  youthful  voice 
had  not  yet  undergone  any  change  one  year  after  the  initial 
implantation,  though  a  second  graft  had  been  introduced  about 
ten  months  after  the  first.  Lichtenstern282  h^s  reported  a  case 
of  gun-shot  wound  necessitating  removal  of  the  testicles  in  a 
man  of  28  years.  Two  weeks  later  sexual  desire  disappeared. 
An  increase  of  the  fatty  tissue  about  the  neck  was.  noted,  to- 
gether with  thinning  of  the  beard.  A  testicle  from  a,  case  of 
inguinal  hernia  was  divided  into  two  parts  and  sutured  in  the 
abdominal  muscles  on  opposite  sides.  Libido  and  erectile 
power  reappeared  on  the  sixth  day,  the  beard  began  to  grow 
thicker  again,  and  the  tissues  of  the  neck  returned  to  normal. 

Lydston's  experiences  have  shown  that  whereas  a  rela- 
tively large  dose  of  the  testicular  product  is  requisite  for  the 
development  of  the  secondary  sex  characteristics,  a  very  small 
dosage  is  sufficient  to  preserve  virility.  Once  virility  has  been 
established,  an  extremely  small  dose  will  preserve  the  psycho- 
sexual  and  physiosexual  characteristics  essential  to  potency. 
Stress  is  laid  by  Lydston  on  the  preservation  of  a  small  quan- 
tity of  normal  testicular  tissue  where  removal  of  the  greater 
portion  of  these  organs  becomes  necessary  because  of  local 
disease. 

ENDOCRINIC  TESTICULAR  OVERACTIVITY. 

Little  is  known  concerning  this  condition,  which,  however, 
at  times  probably  exists.  The  sexual  precocity  at  times  asso- 
ciated with  hypernephromatous  tumors  or  growths  of  the  pineal 
gland  is  presumably  related  to  excessive  activity  of  the  inter- 
stitial testicular  tissue.  It  seems  a  question  whether  among 
normal  males,  excessive  combativeness  and  a  tendency  to  out- 


ENDOCRINIC  DISORDERS  OF  THE  TESTICLES.  191 

bursts  of  violent  temper  may  not  at  times  be  actually  a  mani- 
festation of  unusual  activity  of  the  interstitial  gland  cells, 
constituting,  as  it  were,  an  exaggerated  form  of  a  normal 
secondary  sex  characteristic.  This,  according  to  Sajous,  Sr., 
is  apt  to  attend  the  excessive  use  of  meat.  Unusual  hirsuties 
may  possibly  be  a  similar  manifestation.  Disturbances  of 
other  ductless  g"lands  will,  however,  also  require  consideration 
in  such  cases.  Satyriasis  seems  to  be  due  in  most  cases,  if  not 
always,  to  causes  other  than  endocrinic  testicular  overactivity. 

TREATMENT. 

This  will  necessarily  vary  according  to  the  nature  of  the 
case,  and  in  most  instances  will  be  merely  palliative.  The 
bromids  are  usually  helpful,  in  addition  to  marked  reduction 
of  meat  in  the  diet.  The  .f-rays  might  prove  of  service  to  re- 
duce the  interstitial  testicular  function,  where  palliatives  fail. 
In  some  instances  tumor  formation  in  an  organ  other  than  the 
testes  might  indicate  surgical  removal  of  the  tumor,  as  the 
primary  cause  of  the  exaggerated  sexual  manifestations. 

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13 


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185.  Goetsch,  Gushing  and  Jacobson  :     Bull.  Johns  Hopkins  Hosp.,  1911, 
xxii,  165. 

186.  Goetsch  :    Loc.  cit. 

187.  Blair  Bell.:     Loc.  cit. 

188.  Sajous:     Internal  Secretions,  Ed.  7,  598. 

189.  Gentes :    C.  r.  de  la  Soc.  de  biol.,  1903,  Iv,  100. 

190.  narrower :    Med.  Herald,  1916,  xxv,  361. 

191.  Dunn:    Amer.  Jour.  Med.  Sci.,  1914,  cxlviii,  114. 

192.  Gushing:    The  Pituitary  Body  and  its  Disorders,  Phila.,  1912.  28. 

193.  Gushing :     Op.  cit.,  291. 

194.  Sajous :     Internal  Secretions,  Ed.  7,  1916,  609. 

195.  Timme:    N.  Y.  Med.  Jour.,  1915,  cii,  801. 

196.  Gushing:    Op.  cit.,  p.  321. 


196  BIBLIOGRAPHY. 

197.  Gramegna :     Rev.  neurol.,  1909,  xvii,  15. 

198.  Beclere:     Arch.  Rdntgen  Ray,  1909-10,  xiv,  142. 

199.  Jaugeas :     Les  rayons  de  Rontgen  dans  le  diagnostic  et  traitement 
des  tumeurs  hypophysaires,  etc.,  Paris,  1909. 

200.  Gushing:     Op.  cit.,  p.  291. 

201.  Cope :    Lancet,  1916,  cxc.  601. 

202.  Halstead :     Trans.  Amer.  Surg.  Assn.,  1910,  xxviii,  73. 

203.  Gushing:     Jour.  Amer.  Med.  Assn.,  1914,  Ixiii,  1515. 

204.  Gope  :     Loc  cit. 

205.  Kanavel :     Surg.,  Gynec.  and  Obstet.,  1918,  xxvi,  61. 

206.  Gushing:     Op.  cit.,  p.  42. 

207.  Timme  :    Loc.  cit. 

208.  Evans  and  Assinder :     Birmingham  Med.  Rev.,  1916,  Ixxx,  1. 

209.  Sajous:     Internal  Secretions,  Ed.  7,  1916,  i,  308. 

210.  Pollock :    Jour.  Amer.  Med.  Assn.,  1915,  Ixiv,  395. 

211.  Thomson  and  Lang:     Med.  Ghron.,  1914,  Iviii,  321. 

212.  Salomon:     Presse  med.,  1913,  xxi,  1019. 

213.  Kiipferle  and  von  Szily :     Deut.  med.  Woch.,  1915,  xli,  911. 

214.  Williams:     Wash.  Med.  Annals,  1916,  xv,  103. 

215.  Leszynsky:    Med.  Rec,  19'15,  Ixxxviii,  172. 

216.  Spiller:    Loc.  cit. 

217.  Gushing:    Op.  cit.,  p.  318. 

218.  Kanavel :     Loc.  cit. 

219.  Gushing :     Op.  cit.,  p.  316. 

220.  Gobbledick :     Lancet,  1916,  cxc,  1262. 

221.  Sajous:     Op.  cit.,  1916,  i.  308. 

222.  Gushing :     Op.  cit.,  p.  47. 

223.  Gushing :     Op.  cit.,  p.  320. 

224.  Jordan:     Amer.  Jour.  Anat.,  1911,  xii,  249. 

225.  Ramon  y  Gajal :     Soc.  Espan.  Hist.  Nat,  1895. 

226.  Dandy:     Jour.  Exper.  Med.,  1915,  xxii,  2. 

227.  Horrax :     Arch  of  Internal  Med.,  1916,  xvii,  607. 

228.  Pellizzi :    Riv.  ital.  d.  neuropatol.,  1910,  iii.  193. 

229.  Foa :     Arch.  ital.  de  biol.,  1914,  Ixi,  79. 

230.  Dana  and  Berkeley :    Med.  Rec,  1913,  Ixxxiii,  835. 

231.  McGord :     Surg.,  Gynec.  and  Obstet.,  1917,  xxv,  250. 

232.  Hoskins :     Jour.  Exper.  Zool.,  1916,  xxi,  295. 

233.  McGord  and  Allen :    Jour.  Exper.  Zool.,  1917,  xxiii,  207. 

234.  Marburg:     Wiener  med.  Woch.,   1907,  Ixii,  2512. 

235.  Frankl-Hochwart :     Wiener  med.  Woch.,  1910,  Ix,  505. 

236.  Bailey  and  Jelliffe :     Arch,  of  Internal  Med.,  1911,  viii,  851. 

237.  Bailey  and  Jelliffe :     Loc.  cit. 

238.  McGord :     Interstate  Med.  Jour.,  1915,  xxii,  354. 

239.  Goddard  and  Gornell :     Med.  Rec,  1913,  Ixxxiii,  835. 

240.  Goddard  :    Jour.  Amer.  Med.  Assn.,  1917,  Ixviii,  1340. 

241.  Wallert :     Zeit.  f.  Geburts.  u.  Gynak,  1906,  Ixiii,  520. 

242.  Loeb :     Surg.,  Gynec.  and  Obstet.,  1917,  xxv,  300. 

243.  Schickele :    Arch,  f .  Gynak.,  1912,  Ixxxvii,  409. 


BIBLIOGRAPHY.  197 

244.  Frank :     Surg.,  Gyiicc.  and  Obstet,  1917,  xxv,  225. 

245.  Neumann  and  Hermann:    Wiener  klin.  Woch.,  1911,  xxiv,  411. 

246.  Loewy  and  Richter :     Arch.  f.  Anat.  u.  Physiol.,  1899,  174. 

247.  Murlin  and  Bailey :     Surg.,  Gynec.  and  Obstet.,  1917,  xxv,  332. 

248.  Iscovesco:     Compt.  rend,  de  la  Soc.  de  biol.,  Paris,  1912,  Ixxii,  858. 

249.  Hernnann  :    Monatsch.  f.  Geburtsh.  u.  Gynak.,  1915,  xli,  1. 

250.  Seitz,  Wintz  and  Fingerhut :     Miinch.  med.  Woch.,   1914,  Ixi,  1657 
and  1734. 

251.  Morley:     Surg.,  Gynec.  and  Obstet.,  1917,  xxv,  324. 

252.  Frank  and  Rosenbloom :     Surg.,  Gynec.  and  Obstet.,  1915,  xxi,  646. 

253.  Lefkowitz  and  Frank:    Surg.,  Gynec.  and  Ob.stet.,  1911,  xiii,  36. 

254.  Marshall  and  Jolly :    Edinb.  Med.  Jour.,  1907,  xxi,  219. 

255.  Graves :    N.  Y.  Med.  Jour.,  1917,  cv,  1262.    . 

256.  Sajous  :    Internal  Secretions,  Ed.  7,  1916,  i,  481.  « 

257.  Frank :    Loc.  cit. 

258.  Graves:     Surg.,  Gynec.  and  Obstet.,  1917,  xxv,  315. 

259.  Gordon :    Jour.  Amer.  Med.  Assn.,  1914,  Ixiii,  1345. 

260.  Bandler:     Amer.  Jour,  of  Obstet.,  1917,  Ixxvi,  644. 

261.  Novak:    Jour.  Amer.  Med.  Assn.,  1916,  Ixvii,  1285. 

262.  Hitschmann  and  Adler :    Arch,  f .  Gynak.,  1913,  c,  233. 

263.  Bandler:     Loc.  cit. 

264.  Bucura :     Zentralbl.  f .  Gynak.,  1916,  xl,  816. 

265.  Iscovesco :     Presse  med.,  1912,  xx,  845. 

266.  Lydston  :     Impotence  and  Sterility,  with  Aberrations  of  the  Sexual 
Function  and  Sex-gland  Implantation ;  Chicago,  1917. 

267.  Frank  :     Loc.  cit. 

268.  Bandler :    Loc.  cit. 

269.  Bandler :    Loc.  cit. 

270.  Bouin  and  Ancel :     Compt.  Tend.  Soc.  de  bioL,  1903,  Iv,  1397. 

271.  Shattock  and  Seligmann :     Brit.  Med.  Jour.,  1904,  ii,  SuppL,  11. 

272.  Foges :    Pfliigers  Arch.,  1903,  xciii,  39. 

273.  Smith  and  Crocker:     N.  Y.  Med.  Jour.,  1913,  xcviii,  1. 

274.  Launois  and  Roy :    Etudes  biologiques  sur  les  geants,  Paris,  1904. 

275.  Zoth :    Arch,  f .  d.  ges.  Physiol.,  1896,  Ixii,  335. 

276.  Steinach :     Arch.  f.  d.  ges.  Physiol.,  1912,  cxiiv,  71. 

277.  Dixon:     Pract.,  1901,  Ixvi,  517. 

278.  Stellwagen  :     N.  Y.  Med.  Jour.,  1916,  civ,  879. 

279.  Lydston  :     Op.  cit. 

280.  Lydston  :     Op.  cit. 

281.  Morris :    Jour.  Amer.  Med.  Assn.,  1916,  Ixvii,  741. 

282.  Lichtenstern :    Med.  Klin.,  1916,  xii,  27. 


Diseases  of  the  Cardiovascular 
System 


BY 

J.  NORMAN  HENRY,  M.D., 

Visiting  Physician,  Pennsylvania  Hospital;  Formerly  Clinical  Professor 
of  Medicine,  Woman's  Medical  College  of  Pennsylvania;  formerly 
Assistant   Physician,    Philadelphia    Hospital; 

AND 

S.  CALVIN  SMITH,  Sc.M,  M.D., 

Instructor  in  Medicine,  Jefferson  Medical  College;  Acting  Chief  Clin- 
ical Assistant,  Medical  Clinic,  Jeifferson  Hospital,   Philadelphia. 


(199) 


Diseases  of  the  Cardiovascular, 
System. 


FOREWORD. 

The  time  has  come  when  diseases  of  the  heart  are  to  be 
rewritten  in  the  new  nomenclature  and  broader  understand- 
ing- which  has  been  brought  to  us  by  those  modern  instru- 
ments of  clinical  precision,  the  polygraph  and  the  electrocar- 
diograph. This  work,  coming  as  it  does,  midway  between 
the  older  conception  of  heart  disease  and  the  beginning  of  a 
new  era  of  cardiac  investigation,  must  of  necessity  adapt  itself 
to  both  the  old  and  the  new  regime,  if  it  is  to  be  of  service  to 
the  practitioner  of  medicine. 

The  purpose,  then,  in  writing  this  section,  is  to  present  to 
the  physician  those  distinct  clinical  advances  which  are 
deduced  from  the  highly  specialized  work  being  developed  by 
the  physicist,  the  physiologist,  and  the  pathologist — to  give 
place  only  to  those  cardiac  drugs  whose  value  has  been  estab- 
lished by  recent  investigations,  rather  than  to  burden  our 
pages  with  remedies  which  have  been  adminiatered  empir- 
ically in  the  past. 

The  recently  determined  cardiac  arhythmias  must  take  a 
place  with  the  cardiac  murmurs  of  the  past  generation  in 
being  considered  only  as  symptoms^  which  may  or  ma}'^  not 
call  for  any  treatment  other  than  supervision  and  watchful- 
ness. Where  other  measures  are  indicated,  the  attempt  has 
been  made  to  correlate  modern  treatment  with  the  modern 
conception  of  heart  disease. 

Through  the  courtesies  of  distinguished  investigators, 
electrocardiographic  curves  and  polygraphic  tracings,  which 
illustrate  desired  points,  are  presented.  Thanks  and  appre- 
ciation are  hereby  extended  to  Drs.  Alfred  E.  Cohn,  of  the 
Rockefeller  Institute;  Ross  V.  Patterson,  of  the  Jefiferson 
Medical  College;  Paul  D.  White,  of  the  ]\Iassachusetts  Gen- 

(201) 


202      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

eral  Hospital,  and  Horatio  B.  Williams,  of  the  College  of 
Physicians  and  Surgeons,  of  New  York,  for  the  privilege  of 
drawing  freely  on  their  store  of  valuable  records. 

The  endeavor  has  been  to  make  this  contribution  more 
practical  than  erudite,  more  helpful  than  argumentative,  more 
suggestive  than  didactic — always  bearing  in  mind  what  might 
well  be  called  today's  cardiac  aphorism :  The  muscle  is  of  more 
importance  than  the  murmur;  the  rhythm  is  of  more  importance 
than  the  rate. 


CARDIAC    IRREGULARITIES. 

Irregularities  of  the  heart,  as  shown  by  the  pulse  or  by 
auscultation  at  the  apex,  have  long  been  observed,  and, 
through  the  usage  of  years,  are  generally  believed  to  be  indi- 
cative of  heart  disease.  For  example,  in  days  past,  children 
who  presented  arhythmias  have  been  regarded  as  potential 
heart  cases,  and  their  activities  often  so  curtailed  that  proper 
physical  development  was  interfered  with ;  patients  exhibit- 
ing an  intermittent  pulse  have,  in  days  gone  by,  been  given 
guarded  prognoses  or  perhaps  refused  as  applicants  for  life 
insurance,  and  thereafter  lived  useful,  energetic  lives  for 
twenty-five  years  or  more.  On  the  other  hand,  a  slow  pulse- 
rate  of  50  which  happened  to  be  regular  at  the  moment  of 
examination  was  regarded  as  a  "family  characteristic,"  and 
the  occasional  "far-away"  sensations  which  the  patient  experi- 
enced, or  the  syncopal  attacks  which  he  underwent  at  times, 
were  attributed  to  indigestion  or  to  epilepsy,  with  no  thought 
of  heart  disease  because  no  murmurs  nor  gross  irregularities 
were  present.  Every  practitioner  of  experience  has  noticed 
that  digitalis,  markedly  eftective  in  some  irregularities,  gave 
alarming  symptoms  in  others ;  and  the  profession  has  been  at 
a  loss  to  correlate  such  opposed  observations. 

Today  these  irregularities  are  classified.  We  understand 
that  digitalis  is  beneficial  in  auricular  fibrillation,  and  often 
harmful  in  heart-block;  we  know  that  the  arhythmias  of 
childhood  are  very  often  due  to  a  change  in  vagal  control,  and 
that,  alone  considered,  the}-  are  not  pathologic;  we  appreciate 
that  the  intermittent  pulse  of  adults  is  frequently  due  to  pre- 
mature contractions,  and  that,  in  itself,  it  does  not  constitute 


CARDIAC    IRREGULARITIES.  203 

heart  disease ;  on  the  other  hand,  a  pulse-rate  of  50  or  less  is 
very  suggestive  of  heart-block  of  some  degree,  and  makes  us 
alert  in  repeated  examinations  of  the  patient  to  determine 
whether  such  a  condition  threatens. 

The  masterful  studies  of  Sir  James  Mackenzie,  of  London, 
enabled  him  to  recognize  and  classify  cardiac  arhythmias, 
giving  us  for  the  most  part  clinical  signs  by  which  we  may 
be  guided  in  their  identification.  The  "ink  polygraph"  which 
he  perfected,  together  with  Einthoven's  invention  of  the  elec- 
trocardiograph, have,  under  the  logical  interpretation  of 
Thomas  Lewis,  established  a  new  era  in  the  recognition  of 
diseases  of  the  heart.  Indeed,  the  electrocardiograph  might 
well  be  called  the  quill  with  ivhich  the  heart  records  the  story  of 
its  ozvn  disease.  True,  many  deviations  from  normal  are  not 
yet  interpreted  and  a  vast  array  of  research  problems  remains 
to  be  solved,  yet  results  are  continually  being  obtained  promis- 
ing notable  additions  to  the  brilliant  clinical  contributions  al- 
ready available. 

Cardiac  Physiology.  A  brief  reference  to  the  physiology  of 
the  heart  is  essential  to  the  clear  understanding  of  its 
irregularities. 

The  heart-muscle  is  possessed  of  five  functions,  viz. :  stim- 
ulus production,  conductivity,  contractilit)^,  excitability,  and 
tonicity.  These  functions  may  be  disturbed,  either  singly  or 
in  cornbination,  and  give  rise  to  cardiac  irregularities.  In  the 
healthy  heart,  the  stimulus  for  contraction  arises  at  the  sino- 
auricular  node,  situated  at  the  junction  of  the  right  auricle  with 
the  superior  vena  cava.  From  there  the  stimulus  is  conducted 
along  the  auricle  to  the  auriculoventricular  node,  from  which 
springs  the  neuromuscular  bundle  of  His,  dividing  in  right  and 
left  branches,  and  conducting  the  impulse  from  auricle  to  ven- 
tricles. The  excitation-wave  is  distributed  along  the  arbori- 
zations of  the  branches.  In  disease,  the  stimulus  to  contract 
may  arise  from  one  focus  or  from  multiple  abnormal  foci  in  the 
heart-muscle  instead  of  from  the  normal  "pacemaker,"  the  sino- 
auricular  node;  the  bundle  of  His  may  be  damaged  and 
refuse  to  conduct  the  stimulus ;  or  the  ventricle  may  originate 
stimuli  of  its  own,  quite  independent  of  those  received  from 
the  auricle.  The  polygraph  and  electrocardiograph,  first  used 
to    demonstrate    these    departures    from    the    normal    heart 


204      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

action,  not  only  help  in  their  recognition  and  treatment 
but  have  also  given  means  by  which  many  of  the  disorders 
may  be  clinically  classified  with  a  moderate  degree  of  cer- 
tainty, though  the  graphic  method  of  heart  examination  should 
be  used  when  available. 

Let  us  for  a  moment  follow  the  events  occurring  during  a 
"cardiac  cycle" — that  period  from  the  beginning  of  one  com- 
plete contraction  of  the  heart  to  the  beginning  of  another. 
The  stimulus  for  contraction  arises  in  the  "pacemaker,"  and 
is  conducted  along  the  auricle  to  the  auriculoventricular  node 
and  over  the  bundle  of  His ;  the  mitral  and  tricuspid  valves 
now  stand  open,  and  the  auricles  contract  in  advance  of  the 
ventricles.  The  ventricles  receive  the  stimulus  from  the  ter- 
minal branches  of  the  bundle  at  their  base,  and  the  ventricles 
contract.  The  mitral  and  tricuspid  valves  close.  When  the  in- 
traventricular tension  exceeds  that  in  the  aorta  and  pulmonary 
artery,  the  semilunar  valves  (aortic  and  pulmonary)  open  and 
the  pulse  period  begins.  Ventricular  systole  completed,  relax- 
ation occurs,  and  when  the  intraventricular  pressure  is  lower 
than  that  in  the  aorta  and  pulmonary  artery,  the  aortic  and 
pulmonary  valves  close  and  the  sphygmic  (pulse)  period  ends. 
The  ventricles  further  relax,  the  cuspid  valves  open,  the  blood 
in  the  auricular  reservoir  passes  into  the  ventricle  during  dias- 
tole, and  a  new  cycle  begins. 

The  cardiac  cycle  in  a  normal  heart,  beating  at  the  rate 
of  75  times  a  minute,  occupies  0.8  of  a  second.  Of  this  time, 
0.3  of  a  second  is  occupied  by^  ventricular  systole;  0.5  of  a 
second  by  diastole,  during  the  latter  part  of  which  auricular 
systole  occurs.  Increased  heart-rate  is  almost  entirely  at  the 
expense  of  diastole,  with  shortening  of  the  period  of  rest.  The 
period  which  elapses  from  the  beginning  of  the  auricular  con- 
traction to  the  beginning  of  the  ventricular  contraction  nor- 
mally occupies  from  0.12  to  0.18  of  a  second;  this  is  known  as 
the  A-s  V-s  (auricular  systole  to  ventricular  systole)  period, 
or  as  the  A-C  interval  in  tracings  of  the  venous  pulse,  and  as 
the  P-R  interval  in  the  electrocardiographic  curves ;  any  pro- 
longation of  this  interval  beyond  0.2  of  a  second,  as  determined 
bjr  the  time  measurements  on  either  record,  is  due  to  a  delay 
of  conduct! vit}^  in  the  junctional  tissues.  In  heart-block  it 
may  be  prolonged  to  twice  the  normal  interval. 


CARDIAC   IRREGULARITIES. 


205 


Instruments  of  Pre- 
cision. This  article  is 
not  to  be  burdened 
by  elaborating  on  the 
instruments  for  re- 
cording pulse  trac- 
ings or  electric 
curves ;  either  sub- 
ject, while  most  fas- 
cinating to  those 
who  can  devote 
much  time  to  its 
study,  is  intricate, 
difficult  of  mastery, 
and  not  suited  to  the 
purposes  of  the  prac- 
titioner, in  whose  in- 
terest this  section 
deals.  Consequently, 
only  a  brief  reference 
is  here  introduced. 

M ackenzie' s  ink 
polygraph  is  so 
named  because  it  re- 
cords in  ink,  instead 
of  upon  a  perishable 
smoked  strip,  the 
movements  of  the  ar- 
terial  and  venous 
pulses.  The  apical 
impulse  may  be  re- 
corded instead  of  the 
radial.  Radial  trac- 
ings are  called 
''sphygmograms" 
and  tracing-s  from 
the  apex  "cardio- 
grams" ;  records  of 
the  venous  pulse  are 
termed    ''phlebo- 


^  a 
*'3 


Qj  in 

a  n 

bjoo 


•9  (Si 


l^  il 


2    "^ 


C  CO 

_0   dJ 


OJ      mo 


w 


ai  si 


'i-     •«■ 


< 


^ 


C  o 


.1^ 


CB    to 
O    tn 


,•     P.-1-J 

"^        CO 

CO  r^ 


b  a 

CO  a 


^  <-  fc 


1-  o  ~ 


206       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

grams.''  In  using  the  polygraph,  it  is  necessar^^  to  se- 
cure a  tracing  from  the  jugular  pulse  in  order  to  establish 
the  events  which  transpire  in  the  right  heart.  A  "time-marker" 
(the  notched  lines  at  the  top  of  a  tracing,  0.2  of  a  second  apart) 
and  "ordinates"  (the  vertical  lines  bisecting  the  tracings), 
from  which  to  measure,  as  seen  in  the  accompanying  illustra- 
tions, are  essential  parts  of  the  record.     (See  Fig.  9.) 

The  electrocardiograph  (Fig.  1),  or  "string  galvanometer,"' 
records  upon  a  moving  photographic  film  those  electric  cur- 
rents generated  during  the  contractions  of  the  various  cham- 
bers of  the  heart.  The  deflections  of  the  delicate  wire  actuated 
by  the  heart  currents  van."  in  sequence,  size,  and  incidence, 
and  have  been  proved  by  Lewis  to  have  normal  limits  in  health, 
and  an}'  departure  from  these  normal  limits  indicates  an  ab- 
normal heart.  The  affection  is  perhaps  in  the  auricle,  in  the 
ventricle,  or  in  the  bundle,  as  indicated  by  the  deflections  and 
by  the  time  measurements  recorded  upon  the  film. 

Positive  and  negative  electrodes  are  applied  in  varjang 
combinations  to  the  arms  and  legs  of  the  patient  in  order  to 
establish  the  "leads"  for  the  contraction-wave  generated  at  the 
cardiac  pacemaker  which  travels  through  the  heart  to  produce 
its  contractions.  Three  "leads"  are  usually  taken  from  each 
patient,  the  second  being  the  one  which  gives  the  most  infor- 
mation, although  leads  I  and  III  are  needed  for  comparison 
and  for  further  interpretations.  Lead  Xo.  I  is  from  right  arm 
and  left  arm;  lead  No.  II  from  right  arm  and  left  leg;  lead  No. 
Ill  from  the  left  arm  and  left  leg.  A  set  of  normal  electrocar- 
diograms is  here  illustrated,  the  leads  being  denoted  in  Roman 
numerals.     (See  Fig.  2.) 

The  classification  of  cardiac  arhythmius,  which  we  will  now 
describe  in  the  order  named,  is  as  follows  :* 

\.  Sinus  arhyihmia.  5.  Auricular  fibrillation. 

2.  Premature   contractions.     6.   Heart-block. 

3.  Paroxysmal  tachycardia.     7.  Alternation  of  the  heart. 

4.  Auricular  flutter. 


*  Owing  to  the  fact  that  atrioventricular  rhythm,  auricular  standstill, 
Aentricular  escape,  etc.,  are  not  yet  recognizable  by  ordinary  clinical  means, 
but  are  to  be  detected  only  by  graphic  methods,  their  inclusion  here  would 
serve  no  useful  clinical  purpose. 


CARDIAC    IRREGULARITIES.  207 

1.  Sinus  arhythmias  occur  characteristically  in  the  adoles- 
cent heart,  and  constitute  the  usual  disturbances  of  rhythm 
found  in  the  "youthful"  irregularities.     (See  Fig.  3.)     A  famil- 


Fig.  2. — Normal  Electrocardiogram. 

Three  leads  are  usually  taken,  for  the  purpose  of  comparative  study.  In  this 
and  subsequent  curves  the  lead  is  denoted  by  Roman  numerals  in  the  upper  left 
corner.  The  "abscissEe"  (vertical  lines)  are  time-marks,  representing  0.2  of  a 
second;  the  "ordinates"  (transverse  lines)  measure  0.1  of  a  millivolt.  The  auri- 
cular contraction  is  indicated  by  the  arbitrary  symbol  "P";  the  ventricular  com- 
plex is  expressed  by  the  letters  Q,  R,  S,  T.  Diastole  of  the  heart  is  the  interval 
between  T  and  P.  P,  a  blunt-pointed  elevation,  is  from  1.5  to  2  mm.  in  ampli- 
tude, directed  upward.  The  interval  fromj  the  beginning  of  the  P-wave  to  the 
beginning  of  Q  is  the  conduction]  time  of  the  impulse  from  the  auricular  pace- 
maker along  the  bundle  of  His  to  the  ventricles,  and  normally  occupies  from  0.12 
to  0.18  of  a  second.  In  normal  hearts,  R  is  directed  upward  in  all  leads,  usually 
attaining  its  greatest  amplitude  in  lead  II,  where  it  varies  from  10  to  20  mm. 
The  T-wave,  whiich  expresses  the  end  of  the  ventricular  complex,  is  from  3  to  5 
mm.  in  amplitude  and  is  usually  directed  upward  in  all  three  leads.  (This  record 
is  presented  here  through  the  courtesy  of  Dr.  Paul  D.  White,  of  the  Massachu- 
setts General  Hospital,  Boston.) 

iar  example  is  found  in  the  change  of  rate  in  the  heart  of  a 
young  adult  during  the  act  of  respiration,  the  rate  being  in- 
creased on  inspiration  and  decreased  on  expiration.     Unless 


208      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

accompanied  by  other  evidence  of  cardiac  or  other  affections, 
it  is  not  to  be  reg'arded  as  pathologic,  nor  does  its  detection  indi- 
cate the  administration  of  drug's  or  the  curtailment  of  activities. 
2.  Premature  cotitractions  (also  called  extrasy stoles)  are  ex- 
emplified in  the  "intermittent  pulse,"  the  abnormal  beat  occur- 
ring in  advance  of  the  anticipated  interval,  and  usually  being 
follow^ed  by  a  pause  of  unusual  length.     (See  Fig.  4.) 

Premature  contractions  are  usually  weak,  while  the  suc- 
•ceeding  and  somewhat  delayed  beat  is  unusually  strong, 
because  of  (1)  prolonged  ventricular  rest,  (2)  relatively  low 
intra-arterial  pressure,  plus  (3)  a  greater  accumulation  of 
blood,  all  tending  to  increase  the  volume  of  the  pulse.  White, 
of  Boston,  found  premature  ventricular  beats  the  commonest 
form  of  all  disturbances  of  rhythm, i  with  the  single  excep- 
tion of  the  semiphysiologic  sinus  arhythmia  just  described. 


Fig.  3. — Sinus  Arhythmia. 

This  curve  strikingly  illustrates  the  variations  in  rate  which  characterize  the 
"youthful  type"  of  cardiac  irregularity.  The  sequence  of  events  is  -a  normal  P, 
R,  S,  T  complex,  but  the  rate  varies  with  each  contraction.  (Courtesy  of  Dr. 
Horatio  B.  Williams,  New  York.) 

Premature  auricular  contractions  occur  but  one-third  as  fre- 
quently as  those  arising  in  the  ventricle.  Neither  of  these 
abnormal  beats  receives  its  stimulus  from  the  pacemaker, 
but  from  an  isolated  and  irritable  abnormal  focus.  In  the 
polygraphic  record  the  ventricular  premature  contraction  is 
disting'uished  by  the  fact  that  the  two  normal  beats  preceding 
the  period  of  disturbance  are  of  the  same  length  as  the  abnor- 
mal beat  and  its  predecessor;  this  observation  is  to  be  con- 
firmed by  finding  that  the  "a-wave"  of  the  jugular  tracing  oc- 
curs at  the  regular  interval.  Unaccompanied  hj  other  signs 
of  cardiac  disturbance,  premature  contractions  have  no  great 
significance  and  require  no  treatment;  the  patient  should  be 
kept  under  observation,  and  examined  at  occasional  intervals 
over  a  period  of  time,  until  it  is  established  that  the  disturb- 
ance is  unaccompanied  by  other  evidences  of  cardiac  disorder. 


CARDIAC    IRREGULARITIES. 


209 


3.  Paroxysmal  Tachycardia.  When  the  normal  rate  of  the 
heart  i3  replaced  by  a  period  of  rapid  and  regular  impulses 
varying;  from  120  to  200  per  minute,  which  periods  are  abso- 
lutely abrupt  in  their  inception  and  absolutely  abrupt  in  their 
termination,  paroxysmal  tachycardia  is  present.  The  condition 
is  often  unaccompanied  'by  other  evidence  of  cardiac  disease. 
Paroxysmal  tachycardia  is  recog'nized  clinically  by  a  rapid 
heart-rate  (usually  from  160  to  180),  which  can  best  be  counted 
at  the  apex  rather  than  at  the  radial  artery.  Change  of  position 
from  the  upright  posture  to  the  prone  does  not  alter  the  rate, 
and  the  abrupt  onset  and  the  abrupt  termination  of  the  attack. 


Fig.  4. — Ventricular  Premature  Contractions. 

These  produce  a  trigeminal   pulse.     Note  the  "tripling"   of  the  ventricular 
complexes.     (Courtesy  of  Dr.  Paul  D.   White.) 


whether  it  lasts  for  a  few  minutes  or  for  a  few  weeks,  are  char- 
acteristic. One  patient  described  the  inception  and  termina- 
tion as  resembling  "a  mallet  striking  in  the  chest." 

The  prognosis  depends  upon  the  duration  of  the  attacks, 
upon  their  frequency,  and  upon  the  signs  of  progressive  car- 
diac failure,  as  shown  in  increase  of  the  cardiac  area,  dyspnea, 
signs  of  congestion,  edema,  and  cyanosis.  The  attacks  may 
lead  to  exhaustion  of  the  heart-muscle,  hence  prognosis  will  be 
guarded  when  the  attack  is  long  continued,  despite  the  fact 
that  infrequent  paroxysms  of  but  a  few  hours  usually  ter- 
minate favorably.  Young  patients  may  be  assured  that  the 
attacks,  while  likely  to  recur  at  intervals,  do  not  necessarily 
forecast  a  shortening  of  their  life. 

14 


210       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

Pressure  on  the  right  vagus  nerve,  gently  begun  and  g'rad- 
ually  increased  to  a  point  where  the  carotid  pulsations  are  ob- 
literated, is  effective  in  aborting-  perhaps  one-third  of  the  at- 
tacks. Vomiting-  may  bring  relief.  A  change  of  position  may 
also  be  beneficial. 


Fig.  5. — Marked  Left  Ventricular  Preponderance, 
Showing  Normal  Sinus  Rhythm. 

The  unusual  amplitude  of  the  7?-wave  in  lead  I,  the  marked  S-depression  of 
lead  II  and  the  short  R  plus  the  deep  S  of  lead  III,  are  indicative  of  left  ven- 
tricular preponderance.  These  conditions  are  exactly  reversed  in  the  three  leads 
when  right  ventricular  preponderance  is  present.  Comipare  with  Fig.  7.  (Cour- 
tesy of  Dr.  Paul  D.  White,  of  Boston.) 


CARDIAC    IRREGULARITIES. 


211 


An  ice-bag  applied  to  the  precordium  is  beneficial  in  many 
cases,  and  should  always  be  tried.  Not  only  physical  and 
mental  rest,  but  also  the  induction  of  sleep  is  called  for. 
Morphin  in  the  usual  dose  may  be  safely  employed  for  dis- 
comfort or  for  insomnia.  Venesection  is  rarely  necessary  to 
relieve  engorg'ement  and  congestion.  Lewis  says  that  the 
"continued  wearing  of  a  broad  abdominal  belt,  firmly  applied 
before  rising  and  discarded  on  retiring,  is  sometimes  accom- 
panied by  the  happiest  of  results." 

4.  Auricular  Flutter.  This  is  a  term  arbitrarily  applied  to 
a  submerging  of  the  normal  auricular  beats  in  response  to  a 
series  of  new,  pathologic  impulses  varying  in  rate  from  200 
to  350  per  minute  (Lewis).     (See  Fig.  6.) 

This  rare  condition  differs  from  paroxysmal  tachycardia  in 
the  fact  that  the  enhanced  rate  is  almost  invariably  associated 


Fig.  6. — Auricular  Flutter. 

At  the  beginniug  of  the  curve  the  auricular  rate  is  315,  the  ventricular  rate 
105  per  nuinute;  every  third  auricular  contraction  is  partly  buried  in  the  ven- 
tricular complex.  In  the  latter  portion  of  the  curve  the  auricle  contracts  four 
times  to  each  ventricular  contraction.     (Courtesy  of  Dr.  Horatio  B.  Williams.) 


with  a  failure  of  conductivity  or  contractility.  From  a  single 
abnormal  focus  the  stimulus  for  contraction  arises,  to  drive 
the  auricle  at  a  regular  and  uniform  rate.  The  affection  is 
rare,  and  has  its  greatest  age  incidence  in  the  sixth  decade  of 
life.  In  an  elderly  person  who  presents  a  persistent  ventricular 
action  of  over  120  per  minute,  auricular  flutter  should  be  sus- 
pected and  its  presence  confirmed  by  electrocardiographic  ex- 
amination. Another  suggestive  circumstance  is  the  fact  that 
there  is  absolutely  no  change  in  rate  with  change  of  position  or 
after  exercise  in  a  tachycardia  which  persists  for  weeks  or 
months.  Strangely  enough,  the  symptoms  often  consist  of 
little  more  than  a  sense  of  fatigue ;  the  profound  constitutional 
disturbances  that  one  would  expect  may  be  absent,  except 
when  the  powerful  ventricular  muscle  assumes  response  to 


212       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

ever)'  auricular  contraction,  in  which  event  sig'ns  of  congestion, 
syncope,  and  cardiac  failure  supervene. 

The  condition  is  so  recently  discovered  that  nothing  defi- 
nite can  be  stated  as  regards  the  prognosis.  Until  such  time 
as  we  have  further  light,  the  careful  physician  will  be  guarded 
in  his  prognosis  and  at  the  same  time  avoid  giving  the  patient 
alarm  with  gloomy  forebodings. 

Full  doses  of  digitalis  is  approved  and  efficient  treatment. 
'Following  digitalis  administration,  auricular  fibrillation  often 
occurs,  followed  in  turn  by  normal  sinus  rhythm.  If  the  drug 
cannot  be  tolerated,  full  doses  of  strophanthin,  %5o  to  Yloq 
grain  (0.0004  to  0.0006  Gm.),  intravenously,  may  be  sub- 
stituted. 

5.  Auricula)'  Fibrillation.  This  is  a  condition  in  which  the 
stimuH  for  contraction  arise,  not  in  the  normal  pacemaker,  but 
in  multiple  degenerative  auricular  foci.  In  this  respect 
auricular  fibrillation  differs  from  the  conditions  previously 
considered,  in  all  of  which  only  a  single  irritable  abnormal 
focus  is  at  fault.  The  ventricular  rate  varies,  usually  being 
from  90  to  180;  the  pulse  is  wholly,  continuously,  and  persist- 
ently irregular ;  in  a  succession  of  counts  at  the  apex  and  at  the 
wrist  discrepancies  will  -be  found  in  practically  every  such 
count.  Simultaneous  counting  of  the  rate  at  the  apex  and  at 
the  wrist  shows  a  pulse  deficit,  i.e.,  many  of  the  ventricular 
beats  are  deficient  (incomplete  systoles)  in  reaching 
the  wrist.     Pandemonium  reigns  in  the  heart.     (See  Fig.  7.) 

"Rheumatic"  diseases  of  the  heart  are  responsible  for  fibril- 
lation in  66  per  cent,  of  cases ;  whatever  the  cause,  fibrillation 
of  the  auricles  is  most  frequenth^  associated  with  the  classic 
S3'mpto"ms  of  cardiac  failure— profound  dyspnea,  visceral  con- 
gestion, venous  engorgement,  edema,  anasarca,  etc. 

Auricular  fibrillation,  in  addition  to  the  grossly  and  abso- 
lutely irregular  pulse,  presents  a  symptom  quite  apart  from 
an}'  other  common  cardiac  irregularity,  y'iz.,  in  fibrillation, 
exercise,  emotion  or  fever  (which  raise  the  pulse-rate),  make 
the  irregularity  all  the  more  pronounced;  in  other  common 
disorders  of  the  heart-beat,  exercise  causes  the  irregularit}' 
to  disappear.  As  the  heart  slows,  the  irregularity,  in  other 
disturbances,  becomes  more  evident,  but  in  fibrillation  the 
irregularities   becoiJie    /<?,?,?   eA-ident.     This   variability    of   the 


CARDIAC    IRREGULARITIES. 


213 


irregularity  is  of  profound  clinical  significance.  A  rate  of 
over  120  in  a  pulse  that  is  absolutely  irregular  is  almost  con- 
clusive evidence  of  auricular  filjrillation.  A  presystolic  mur- 
mur and  thrill  existing-  previous  to  the  onset  of  fibrillation 
usually  disappear  when  fibrillation  occurs,  owing  to  the  in- 
activity of  the  auricle,  .maintained  in  a  position  of  trembling 
diastole  and  failing  to  contract.  This  condition  well  illustrates 
the  errors  which  constantly  occur  in  estimating  the  ventricular 


Fig.  7. — Auricular  Fibrillation. 

The  vemtricular  rate  has  been  slowed  by  digitalis.  Note  the  substitution  of 
fibrillary  waves  for  the  normal  P-peak  (as  shown  in  Fig.  2).  Note  also  that  in 
this  set  of  curves  the  R-  and  S-  waves  take  a  position  in  the  leads  the  reverse 
of  that  in  Fig.  2,  thus  giving  us  rif/ht  ventricular  preponderance.  Further  note 
in  leads  II  and  III,  that  the  T-wave  is  "digitalized,"— that  is,  either  decreased 
In  amplitude  or  inverted;  a  change  which  has  been  observed  within  thirtv-six 
hours  following  the  initial  administration  of  the  drug,  and  which  may  continue 
for  twenty-two  days  following  its  withdrawal.     (Courtesy  of  Dr.  Paul  D.  While.) 

contraction  by  the  pulse-rate  alone ;  in  fibrillation  it  is  not  in- 
frequent to  find  a  radial  pulse  of  perhaps  64  and  a  ventricular 
rate  of  130,  showing  that  many  of  the  beats  fail  to  reach  the 
wrist,  and  emphasizing  the  fact  that  the  ventricular  rate  should 
be  simultaneously  estimated  at  the  chest  wall  and  at  a  con- 
venient artery. 


214      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

As  may  readily  be  imagined,  the  sounds  are  much  altered 
in  the  tumultuous  heart.  When  a  beat  is  missed  at  the  wrist, 
the  first  sound  alone  may  be  heard ;  when  the  beats  are  weak, 
so  are  the  sounds;  systolic  murmurs,  previously  present,  may 
be  heard  in  fibrillation  except  when  the  rate  is  so  fast  that 
they  vanish.     (See  Fig.  8.) 

Fibrillation  is  an  evidence  of  profound  damage  to  the  mus- 
culature of  the  heart.  Fortunately  it  is  amenable  to  remedial 
measures,  and,  while  a  serious  symptom,  is  not  by  any  means 
to  be  considered  immediately  fatal.  If,  in  spite  of  therapeutic 
efforts,  a  ventricular  rate  of  over  120  per  minute  is  maintained, 
the  outlook  becomes  progressively  grave  in  proportion  to  the 
rate  maintained.  The  converse  applies — if  a  lower  ventricular 
rate  is  maintained  without  the  use  of  drugs,  the  prognosis  is 
that  much  more  favorable. 


Fig.  8. — Auricular  Fibrillation. 

Showing  an  "ectopic"  ventricular  complex.  An  ectopic  ventricular  complex 
arises  from,  an  abnormal  focus  of  impulse  production  within  the  ventricle;  as 
the  contraction  does  not  proceed  along  the  normal  pathway  of  conduction  in 
normally  beating  hearts,  the  rhythm  is,  of  course,  disturbed  (Fig.  4),  but  here 
there  is  no  rhythm  to  interrupt,  hence  the  electrocardiograph  affords  us  the  only 
means  of  detecting  the  abnormal  contraction.  (Courtesy  of  Dr.  Paul  D.  White, 
Boston.) 

In  the  treatment  of  auricular  fibrillation  digitalis  has 
achieved  a  brilliant  reputation.  Now  that  the  condition  can 
be  definitely  distinguished  from  other  heart  disorders,  the  early 
exhibition  of  the  tincture  in  10-  to  15-  drop  (0.60-  to  0.92-  mil) 
doses  four  times  daily  is  attended  with  results  that  are  usually 
prompt  and  gratifying.  When  the  heart-rate  falls  to  90,  the 
dose  is  reduced,  and  when  it  approaches  normal  the  drug  is 
maintained  at  a  dosage  sufficient  to  continue  its  effect.  The 
appearance  of  "digitalis  coupling"  (see  Fig.  20),  in  which  the 
beats  occur  in  pairs  or  in  triplets,  a  large  beat  being  closely  fol- 
lowed by  one  of  smaller  volume,  is  a  signal  for  cessation  of  the 
drug.    When  urgent  symptoms  of  fibrillation  are  seen,  and  the 


CARDIAC    IRREGULARITIES.  215 

heart-rate  is  above  170,  strophanthin  in  doses  of  ■'/(.50  grain 
(0.0002  Gm.)  may  be  given  intravenously,  and  repeated  in  two 
hours ;  a  third  dose  is  not  frequently  required,  as  the  heart- 
rate  falls  to  perhaps  90  within  from  six  to  twelve  hours.  Stro- 
phanthin. according  to  Lewis,  is  to  be  confined  to  the  "rheu- 
matic group"  of  cases  in  which  the  preferal^le  drug,  digitalis, 
occasionally  produces  symptoms  of  gastric  disturbances. 
Venesection  may  be  indicated,  between  20  and  30  ounces  (600 
and  900  mils)  of  blood  being  withdrawn,  to  relieve  the  venous 
congestion. 

The  physician  will  exercise  his  judgment  as  to  whether  or 
not  each  individual  case  of  auricular  fibrillation  shall  be  con- 
fined to  bed,  always  remembering  that  cardiac  exhaustion  may 
rapidly  develop  at  any  time.  Those  who  present  more  serious 
symptoms  of  cardiac  disturbance  and  those  of  the  higher 
■heart-rate  will,  of  course,  be  given  the  benefit  of  absolute  rest, 
but  milder  degrees  of  the  disorder  may  not  require  this  caution- 
ary measure. 

It  is  to  be  remembered  that  belladonna  and  atropin  are  be- 
lieved to  increase  the  conductivity  of  the  bundle  of  His,  a  con- 
dition which  we  absolutely  wish  to  avoid  in  fibrillation.  It  is 
for  the  purpose  of  decreasing  the  conduction  of  the  haphazard 
auricular  impulses  that  we  employ  digitalis  so  successfully  in 
this  condition. 

On  account  of  the  frequent  association  of  auricular  fibril- 
lation with  "rheumatic"  diseases  of  the  heart  (wbich  word  is 
but  a  cloak  for  septic  absorption  from  various  foci  of  suppura- 
tion within  the  economy),  this  seems  an  appropriate  place  to 
mention  that  in  all  heart  disturbances  a  search  should  be  made 
for  the  hidden  focus  of  infection.  It  may  be  found  in  suppu- 
rative ear  or  nasal-sinus  conditions ;  perhaps  the  nidus  exists 
in  unhealthy  tonsils ;  pyorrhea  alveolaris  may  possibly  furnish 
the  infection ;  the  appendix  may  act  as  a  host  for  streptococci ; 
gall-bladder  infections  or  pyelitis  may  be  unsuspected  causes 
of  septic  absorption.  But  that  cause  so  frequently  at  the  base 
of  septic  absorption  and  so  frequently  overlooked  is,  in  our 
opinion,  apical  abscess  of  the  teeth.  The  physician  should  not 
be  satisfied  with  the  statement  of  the  patient  that  his  teeth 
were  recently  pronounced  to  be  in  healthy  condition.  A  nega- 
tive report  from  the  dentist  should  not  disarm  the  suspicion  of 


216      DISEASES    OF   THE    CARDIOVASCULAR  'SYSTEM. 

a  dental  cause  when  the  conviction  once  has  been  established ; 
only  upon  the  receipt  of  a  neg'ative  a"-ray  examination,  in 
which  the  entire  denture  has  been  photographed,  should  ab- 
scessed teeth  be  excluded  from  consideration.  The  absence 
of  larg'e  pockets  of  pus  in  the  .I'-ray  film  does  not  exclude  the 
teeth  as  possible  foci  of  suppuration.  Bliss^  informs  us  that  at 
the  first  examination  the  rontgenologist  may  find  only  some 
thickening  or  irregularity  of  the  peridental  membrane,  but  that 
an  exposure  made  at  a  later  date  may  show  a  slightly  darker 
area  around  the  apex  of  the  tooth,  indicating  that  absorption 
has  taken  place.  Owing  to  the  fact  that  dentists  of  earlier 
days  did  not  fill  the  canal  of  the  tooth  down  to  and  throvigh 
the  apical  foramen,  but  proceeded  to  crown  it,  unmindful  of 
this  precaution  which  the  .I'-ray  has  determined  as  absolutely 
necessary  for  safe  results,  capped  teeth  are  to  be  regarded  with 


a.  c      V  a-  ^   ^      V  a  a  c     v  a 


a-c  Interval  o.  3  Sec. 


Fig.  9. — Partial  Heart-block 

The  auricles  are  contracting  regularly  at  tlie  rate  of  66  per  minute.  Stimulus 
conduction  to  the  ventricle  occurs  eveiT  other  beat,  although  the  conduction  is 
delayed  (0.3  of  a  second) ;  each  alternate  stimulus  fails  absolutely  (.block) ;  the 
ventricular  rate  is,  therefore,  one-half  that  of  the  auricular  (2:  1  rhythm).  The 
ventricular  systole  is  0.4  of  a  second  in  duration;  diastole  is  1.4  seconds  in  length, 
the  departure  from  the  normal  rate  being  chiefly  occasioned  by  an  increase  In 
the  length  of  diastole.     (Courtesy  of  Dr.  Ross  T.  Patterson.) 

suspicion,  whether  or  not  they  g"ive  sensations  of  elongation, 
pain,  or  tenderness. 

6.  Heart-block  is  a  condition  in  which  the  impulse  conduction 
from  auricle  to  ventricle  is  delayed  or  absent.  The  suspicion 
of  heart-block  should  be  aroused  in  heart-rates  of  50 ;  it  is 
almost  certainly  present  in  rates  as  low  as  35  per  minute. 
(See  Fig.  9.) 

The  transmission  of  the  excitation  wave  from  auricle  to 
ventricle  follows  along  the  bundle  of  His.  Mild  grades  of 
'loss  of  function  of  the  bundle  of  His  are  evidenced  by  pro- 
longation of  the  A-s  to  Y-s  interval  of  0.18  of  a  second.  Slight 
grades  of  heart-block  are  evidenced  by  an  occasional  total  fail- 
ure of  conduction,  giving"  rise  to  a  "dropped  beat,"  in  which 


3.S  ^-6  24- 

Fig.  10. — Complete    Heart-block    with    Syncopal    and   Epileptiform   Seizures    (Stokes- Adams   Sj'ndrome). 


The  auricles  { 


SGCDDds'  duration  ] 


of  each  beat  i 


:idental.     The  rapid  auricular  r 
t  seconds.     The  effects  of  auricular  contractions  upon  the  ventrl 

I  the  last  one  of  which,  attended  by  a  cry,  death  occurred  eighteen  hours  after  the  record  sho 


exhibited  between 


the  cardiogram  I 


CARDIAC    IRREGULARITIES. 


217 


ventricular  silence  occurs  for  twice  the  normal  interval.  These 
may  later  recur  at  more  frequent  and  regular  (or  irregular) 
intervals,  as,  for  example,  every  eighth  or  tenth  heat;  succeed- 
ing upon  this  in  more  advanced  degree  we  encounter  a  "2:1 
rhythm,"  in  which  the  auricle  beats  twice  for  every  ventricular 
contraction;  or  a  "3:1"  -or  "4:1"  rhythm  may  be  established. 
(See  Fig.  10.) 

The  extreme  degree  is  that  of  complete  dissociation  of 
auricle  and  ventricle,  in  which  no  stimuli  for  contraction  are 
transmitted ;  the  ventricle  may  then  be  forever  stilled,  or  it 
may  initiate  a  rhythm  of  its  own  at  a  rate  approximating  30 
per  minute.  When  ventricular  silence  extends  over  ninety 
seconds  death  results. ^ 

When    the    ventricular    silence    lasts    over    three    or    four 


Fig.   11. — Complete   Heart-block. 

The  P-R  interval  is  normally  from  0.12  to  0.18  of  a  second  in  duration.  Here 
there  is  complete  dissociation  of  auricular  and  ventricular  contractions.  Com- 
pare this  curve  with  the  normal  sequence  of  events  in  Pig.  2.  (Courtesy  of  Dr. 
Paul  D.  White.) 


seconds,  the  Stokes-Adams  syndrome  may  be  manifest,  in  vary- 
ing degrees  of  intensity.  This  condition,  which  is  dependent 
upon  an  arrest  of  the  blood  supply  to  the  brain,  is  character- 
ized by  slow  ventricular  and  rapid  auricular  rates  of  contrac- 
tion, attended  by  syncope,  epileptiform  convulsions,  and  visi- 
ble venous  pulsations  in  the  neck,  occurring  more  frequently 
than  the  arterial  beats.  The  milder  degree  of  this  syndrome  is 
characterized  by  a  far-away  sensation,  perhaps  by  a  feeling  of 
dizziness  or  momentary  loss  of  consciousness,  and  by  muscular 
twitching. 

The  polygraph  and  the  electrocardiograph  afiford  the 
surest  methods  of  determining  the  presence  and  the  degree 
of  heart-block,  and  the  use  of  the  instruments  is  essential  for 
a  diagnosis.     Silence  of  the  ventricle,  rapid  undulations  of  the 


218       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

veins  of  the  neck,  the  frequent  (but  by  no  means  constant) 
presence  of  the  Stokes-Adams  syndrome,  the  possible  halving 
of  the  ventricular  rate,  and  a  modification  of  the  heart  sounds, 
in  which  auricular  contraction  during  ventricular  silence  may 
give  rise  to  a  third  sound,  are  very  suggestive  clinical  symp- 
toms ;  taken  in  connection  with  a  pulse-rate  of  50  or  lower,  they 
furnish  a  symptom-complex  which  calls  for  the  treatment  em- 
ployed in  this  condition.  In  very  mild  attacks,  the  patient 
is  pulseless  and  momentarily  pale,  and  in  more  severe  attacks, 
giddiness,  fainting,  and  temporary  loss  of  consciousness,  with 
muscular  contractions,  prevail. 

Heart-block  is  to  be  regarded  as  an  evidence  of  serious 
muscular  change ;  it  is  not  probable  that  this  damage  is  limited 
to  the  bundle  alone,  but  more  than  likel)'-  that  the  bundle 
shares  in  the  general  degeneration  of  cardiac  tissues.  Conse- 
quently, deaths  from  heart-block  are  deaths  that  arise  from 
heart-failure,  and  not  from  any  conditions  peculiar  to  the 
block.  So  we  must  arrive  at  the  prognosis  in  heart-block  by 
estimating  the  amount  of  myocardial  degeneration  present,  as 
shown  by  the  severity  and  persistence  of  the  usual  cardiac 
lesions. 

Patients  with  the  milder  grades  of  heart-block  need  not 
be  confined  to  their  beds,  but  may  be  up  and  around;  even 
patients  with  the  higher  grades  may  attend  to  their  usual 
duties,  unless  the  signs  of  cardiac  failure  supervene. '  Treat- 
ment is  directed  to  the  underlying  condition ;  if  syphilis  be  the 
causative  factor,  antisyphilitics  are  employed.  If  "transitory" 
block  arises  in  the  course  of  an  acute  disease,  such  as  the 
writer  has  observed  in  erysipelas,  normal  rhj^thm  may  initiate 
itself  without  any  treatment.  The  failing  heart  muscle  may 
require  digitalis  support,  although  its  administration  must  be 
attended  with  extreme  watchfulness  and  care,  as  the  drug  may 
convert  an  incomplete  heart-block  into  complete  block.  If 
complete  block  be  present,  digitalis  cannot  make  it  more  com- 
plete, and  by  its  action  on  the  cardiac  muscle  may  prolong  life. 
Atropin,  by  a  possible  effect  of  increasing  the  conductivity  of 
the  bundle  of  His,  is  the  indicated  remedy  in  all  degrees  of  heart- 
block.  It  is  given  in  doses  of  ^oo  grain  (0.0006  Gm.),  repeated 
as  indicated  for  effect.  Urgency  may  indicate  the  hypodermic 
use  of  the  drug.     (See  Fig.  12.) 


CARDIAC    IRREGULARITIES. 


219 


In  heart-block  produced  in  canines  by  forceps-pressure, 
epinephrin  injections,  according  to  the  experiments  of  Heitz,* 
will  restore  auricular  beats  of  140  and  ventricular  beats  of  55 
to  a  common  level  rate  of  115  w^ithin  twenty  seconds,  but  the 
effect  soon  is  lost,  and  we  await  further  evidence  to  establish 
the  clinical  value  of  the  drug  before  advising  its  use. 

7.  Alternation  of  the  Heart.  This  is  a  condition  in  which  the 
pulse,  regular  in  rhythm  but  varying  in  volume,  alternates  in 


cv  acv    o-cv    acv   acv    acv    acv    acv   acv    acv 


acv    acV-    acV 


acV    acv    acv 


Fig.  12. — Effects  of  Atropin  in  Heart-block. 

Same  patient  as  Fig.  9,  after  the  administration  of  atropin  sulphate 
Veo  to  1/50  grain  (0.0011  to  0.0012)  t.  i.  d.  for  seiveral  days.  A  twelve-minute 
tracing  showed  alternating  periods  of  normal  rhythm  and  2:  1  block  of  about' 
forty  seconds'  duration  each.  The  transition  from  one  rhythm  to  the  other  was 
sometimes  abrupt;  ati  others  irregular  conduction  caused  arhythmia  for  a  few 
seconds.  The  section  shown  above  (.4)  was  from  a  portion  in  which  no  block 
occurred.  Conduction  from  auricle  to  ventricle  occurs  in  the  nonnal  time  (0.2 
of  a  second).  The  ventricular  (and  auricular)  rate  is  60  per  minute.  Systole  is 
0.3  of  a  second  in  duration;  diastole  0.7  of  a  second.  The  atropin  was  continued 
and  a  few  days  later  all  block  disappeared,  and  did  not  recur  before  discharge  a 
short  time  thereafter,  as  shown  in  the  tracing  (B)  which  follows.  (Courtesy  of 
Dr.  Ross  V.  Patterson.) 


the  height  of  every  other  wave.  It  is  more  frequently  seen  in 
advancing  years  in  arteriosclerotic,  nephritic,  and  anginal 
patients. .  We  do  not  wish  to  convey  the  impression  that  the 
pulsus  alternans  is  not  encountered  in  acute  infections  and  in 
the  young,  for  it  is  associated  with  conditions  which  produce 
exhaustion  of  the  heart-muscle,  either  acute  or  chronic.    Alter- 


220      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

nation   is   due  to  an   impairment  of  contractility.      (See   Fig. 

13.) 

If  the  physician  is  to  depend  upon  the  detection  of  the  pul- 
sus alternans  by  the  use  of  the  examining-  finger  alone,  it  will 
usually  escape  detection,  for  the  alternate  waves  may  be  so 
small  as  to  escape  detection  at  the  wrist.  The  sphygmogram, 
however,  records  their  occurrence  faithfully.  In  extreme 
cases  the  alternations  appear  in  the  entire  length  of  the 
tracing.  A  clinical  recognition  of  alternation  can  be  estab- 
lished b}^  placing  the  cufi  of  a  blood-pressure  apparatus 
around  the  arm  and  inflating  it  to  that  point  where  the  weaker 
beats  disappear  at  the  wrist.  Halving  of  the  pulse-rate  in  this 
manner,  while  subject  to  error  if  the  force  of  the  smaller  waves 


'^N 

ae. 

V 

*'v 

aC 

• 

'«T;s!srsis»ifT»tfirm»«E«Bjr»«»i5 . 

1 

Fig.  13. — Alternation  of  the  Pulse. 

A  very  excellent  example  of  pulsus  alternans  is  shown.  In  two  places  the  al- 
■  temation  of  large  and  small  beats  is  broken  by  the  occurrence  of  two  small  beats. 
The  small  beats  are  incomplete  failures  of  contractility  on  the  part  of  the  ven- 
tricle. The  irregularity  is  one  of  volume  only,  the  sequence  being  regular.  Pul- 
sus ullernans  occurs  in  conditions  in  which  there  is  some  serious  affection  of  the 
myocardium  force,  and  is  of  unfavorable  prognostic  import.  The  above  tracing 
was  made  from  a  patient  with  evidence  of  fibrofatty  myocardial  degeneration  and 
progressive  cardiac  insufiBciency.     (Courtesy  of  Dr.  Ross  V.  Patterson.) 

be  comparatively  high,  or  so  faint  as  to  be  barely  perceptible, 
should,  nevertheless,  be  of  clinical  significance  to  the  physician 
remote  from  graphic  records. 

The  prognosis  is  that  of  the  provocative  condition.  If 
acutel}-  produced  by  toxic  influences,  in  a  heart  that  gave  no 
evidence  of  previous  affection,  and  if  tending  to  disappear  after 
rest,  a  pulsus  alternans  of  infrequent  recurrence  is  not  of 
serious  prognostic  import.  The  majority  of  cases,  however, 
are  cardiopathic,  and  so  associated  with  evidence  of  serious 
cardiac  damage  that  the  induction  of  the  pulsus  alternans 
is  premonitory  of  the  end.     Frequentty  it  may  presage  death 


CARDIAC    IRREGULARITIES.  221 

when  Cheyne-Stokes  respiration,  angina,  and  other  terminal 
symptoms  are  absent.  Mackenzie  found  that  the  average 
length  of  life  was  two  years  following  its  detection.  Of  Paul 
D.  White's  71  cases,  25  succumbed  within  ten  months.-"* 

The  detection  of  alternation  of  the  heart  requires  prompt 
change  from  an  active  mode  of  life  to  one  that  will  conserve 
the  output  of  energy  and  lessen  the  demand  upon  the  weak- 
ened heart-muscle.  It  is  to  be  borne  in  mind  that  physical 
exertion  is  not  the  only  factor  that  imposes  demands  upon  the 
heart,  for  psychic  disturbances,  emotion,  and  close  mental  ap- 
plication are  no  less  drastic  in  their  demands  upon  the  weakened 
myocardium.  That  long  periods  of  rest  are  indicated  goes 
without  saying;  the  diet  must  be  easily  assimilated,  and 
limited  in  protein  constituents ;  the  emunctories  of  the  body — 
the  bowels,  kidneys,  and  skin — kept  in  a  healthily  active  state  ; 
and  the  occurrence  of  gastrointestinal  disturbances,  with  their 
attendant  heart  load,  vigorously  combated.  Digitalis  in  10- 
to  15-  drop  (0.6  to  0.9  mil)  doses  t.  i.  d.,  may  be  required  to 
support  the  cardiac  muscle,  its  administration  being  carefully 
watched  for  the  untoward  effects  detailed  at  length  in  the 
discussion  of  this  drug.     (See  p.  278.) 

In  the  management  of  cardiopaths  it  is  not  enoug-h  that 
the  physician  content  himself  with  the  institution  of  a  hygienic 
and  dietetic  regimen  and  with  the  instruction  of  the  patient 
concerning  rest.  It  is  his  duty  to  see  that  such  instructions 
are  obeyed,  and  that  all  sources  of  annoyance  that  might 
perturb  an  irascible  patient  are  removed.  As  an  illustration 
of  the  extremes  of  irritability  common  in  men  of  dominant 
nature  who  are  forced  from  the  activities  of  leadership  into  a 
period  of  invalidism,  we  cite  the  instance  of  a  venerable  banker 
of  our  acquaintance.  Naturally  of  a  genial  and  cordial  nature 
in  health,  he  was,  nevertheless,  thrown  into  torrents  of  rage, 
which  induced  grave  cardiac  symptoms,  when  his  nurse,  in  an 
adjoining  room,  used  her  handkerchief  in  a  most  unobtrusive 
manner.  Trivial  and  unwarranted  as  was  this  cause  of  emo- 
tional disturbance,  its  immediate  effect  on  the  cardiopath  was 
no  less  pronounced  than  would  have  been  the  news  of  a  busi- 
ness calamity  brought  to  him  by  the  friends  wdiom  we  ex- 
cluded from  the  sick-room.  The  incident  is  metioned  here  in 
the  hope  that  it  may  be  of  service  to  others  in  searching'  for 


222       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

the  hidden  cause  of  a  failure  to  improve  under  circumstances 
apparently  most  propitious. 

PERICARDITIS. 

Of  the  six  affections  of  the  pericardium,  those  which  we 
recognize  clinically  are:  (1)  dry  pericarditis  (also  called  plas- 
tic or  fibrinous,  the  "shagg}""  heart)  ;  (2)  pericarditis  with 
effusion  (either  serous  or  purulent)  ;  (3)  pericardial  adhesions 
(adherent  pericardium)  ;  the  two  last-mentioned  frequently 
being  gradually  progressive  steps,  as  a  result  of  the  fibrinous 
inflammation  of  the  sac.  The  other  occasional  forms  present- 
ing a  less  definite  symptom-complex  are  hydropericardium, 
hemopericardium,  and  pneumopericardium.  The  three  last  mav 
be  conveniently  disposed  of  here  with  a  brief  consideration  of 
each. 

Hydropericardium  is  a  transudate  occurring  as  a  part  of  a 
general  anasarca,  and  presenting  no  physical  signs  by  which  it 
may  be  differentiated  from  an  inflammatory  effusion. 

Hemopericardium^  which  results  from  a  stab  or  other 
wounds  that  permit  the  ingress  of  blood  into  the  pericardial 
sac,  is  of  necessity  rapidh^  fatal,  and  hence  not  clinically 
demonstrable. 

Pneumopericardium,  or  the  presence  of  air  or  gas  in  the 
pericardial  cavity,  has  been  recognized  on  less  than  fifty  occa- 
sions in  medical  literature.  The  air  enters  through  a  wound 
of  the  sac,  arising  as  a  result  of  stab  or  gunshot  wounds,  of 
compound  fractures  of  the  thorax,  of  ulcerative  processes  ex- 
tending from  other  viscera,  or  through  a  misdirected  paracen- 
tesis of  the  thorax.  The  diagnosis  is  based  on  the  presence  of  a 
splashing,  churning,  mill-wheel  sound,  such  as  might  be  ex- 
pected from  the  movements  of  the  heart  within  a  sac  contain- 
ing fluid  in  the  presence  of  air.  The  .r-ray  may  adduce  con- 
firmatory evidence. 

Before  entering  upon  an  extended  consideration  of  affec- 
tions of  the  pericardium,  it  may  be  well  to  recall  the  physio- 
logic purpose  of  that  membrane.  Normally,  Bernard  has  told 
us,  it  is  an  inextensible  support  for  a  dilating  heart,  and  is 
capable  of  resisting  an  intense  pressure  of  more  than  one 
atmosphere.     This  obser^'ation  has  recently  been  confirmed^ 


PERICARDITIS.  223. 

by  experimental  removal  of  the  sac  in  animals,  a  procedure 
followed  by  a  functional  irregularity,  by  venous  overdis- 
tension, and  by  incompetence  of  the  mitral  and  tricuspid 
valves.  Gradually  the  myocardium  dilated  to  the  point  of  rup- 
ture, first  of  the  outer  layers,  but  ultimately  of  the  entire  left 
ventricular  wall. 

Experimental  distension  of  the  pericardium  by  the  intro- 
duction of  oiF  was  followed  by  a  steady  rise  of  venous  pres- 
sure, althoug-h  the  aortic  pressure  at  first  remained  constant; 
but  when  the  intrapericardial  pressure  rose  to  such  a  height 
that  it  prevented  the  filling  of  the  heart  during  diastole,  the 
supply  of  blood  to  the  ventricles  failed,  the  pulse  became  small, 
and  the  blood-pressure  rapidly  fell. 

These  experiments  are  of  interest  when  one  considers  the 
amount  of  pericardial  effusion  frequently  withdrawn  clinically. 
A  normal  pericardium  can  hold  less  than  1^  pints  (710  mils) 
of  fluid,  and  yet  amounts  far  in  excess  of  this,  even  to  the 
case  reported  by  Gibson,  where  a  gallon  (4  1.)  of  fluid  was 
withdrawn,  are  not  incompatible  with  ultimate  recovery. 
One  is  almost  forced  to  conclude  that  the  effusion  occurring 
in  pericarditis,  up  to  an  undetermined  limit,  exerts  a  bene- 
ficial, mechanically  retarding  effect  on  a  heart  affected  by  the 
toxins  of  disease ;  and  the  plastic  pericardium,  also,  may  by  its 
inhibiting  effect  on  a  threatened  heart,  to  some  degree  be 
considered  as  a  manifestation  of  conservative  effort  on  the 
part  of  nature.  , 

Speculative  as  such  a  conception  must  necessarily  be, 
the  fact  remains  that  pericardial  effusions,  naturally  produced, 
rarely  embarrass  heart  action ;  experimentally  produced  on  an 
apparently  normal  heart  of  a  dog,  much  cardiac  embarrass- 
ment arises.  Statistics  are  unavailable  affording  light  on  the 
mortality  occurring  in  pericardial  effusion  treated  by  aspirat- 
ing the  fluid,  as  compared  with  the  figures  obtained  by  treat- 
ment other  than  surgical  intervention. 

Pericarditis,  rare  as  a  primary  event,  is  usually  associated 
with  other  diseases  in  which  initial  attacks  of  acute  rheumatic 
fever  hold  first  etiologic  place.  Its  incidence  is  greater  in 
proportion  to  the  severity  of  the  arthritis,  according  to  Ger- 
rod,  and  rarely  exists  with  the  milder  "rheumatic"  affections 
so  frequently  attended  by  endocarditis.     Within  eleven  days 


224      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

of  the  onset  of  arthritic  symptoms,  Gibson  detected  pericarditis 
in  50  per  cent,  of  his  cases.  Chorea  and  tonsillar  infections  are 
common  etiologic  factors. 

Other  infections  rarely  induce  pericarditis.  It  may  occur 
in  3  per  cent,  of  cases  in  pneumonia,  and  in  less  than  1  per 
cent,  in  scarlet  and  enteric  fevers.  Arising  in  the  course  of 
chronic  conditions,  it  is  frequently  associated  with  Bright's 
disease  and  diabetes.  Tuberculous  infections  of  the  pericar- 
dium are  not  rare.  Pyemia  may,  of  course,  induce  pericarditis, 
as  may  extension  of  an  inflammation  from  contiguous  organs 
or  perforating  wounds  of  the  sac  itself.  Sex  and  occupation 
are  irrelevant;  a  study  of  age  incidence  suggests  that  the 
pericardium  should  always  be  regarded  with  anxiety  in  the 
"rheumatic"  aiTections  of  childhood. 

Pericardial  inflammation  so  often  fails  to  reveal  itself  by 
either  subjective  or  objective  signs  that  its  discovery  is  fre- 
quently accidental.  According-  to  Robey^  this  condition  was 
clinically  recognized  only  100  times  in  34,467  patients  at  the 
Boston  City  Hospital,  and  12  times  in  78  autopsies  performed 
at  the  same  institution.  Attention  is  often  first  called  to  it  as 
the  result  of  detecting  a  to-and-fro  murmur,  produced  by  the 
friction  movements  induced  b}'  the  heart  in  the  inflamed  peri- 
cardial membrane.  This  murmur,  when  present,  is  quite  char- 
acteristic. Pain  is  of  rare  occurrence,  and  ^Mackenzie  believes 
it  to  be  present  only  when  the  myocardium  is  involved. 

Pericardial  friction  may  be  palpated,  but  auscultation 
afifords  a  better  opportunity  to  make  a  differential  study  of 
this  single  physical  sign  in  dry  and  fibrous  pericarditis. 
On  listening  at  the  junction  of  the  fourth  left  rib  with  the 
sternum,  a  grating,  to-and-fro.  superficial,  leather}'  sound  rarely 
bearing  any  relation  to  the  cardiac  cycle  is  audible.  It  is  in- 
constant in  intensity — now  of  greater,  now  of  lesser  volume ; 
it  may  disappear  for  a  few  hours,  depending  on  the  strength 
of  the  cardiac  contractions,  and  may  be  intensified  if  the  pa- 
tient be  examined  in  a  sitting  posture.  Pressure  of  the  stetho- 
scope may  exaggerate  the  to-and-fro  murmur.  Pleural  friction 
sounds  need  confuse  us  only  long  enough  to  instruct  the 
patient  to  hold  his  breath  at  the  end  of  expiration.  Pericardial 
friction  is  then  discovered  still  to  be  present,  and  to  be  inten- 
sified by  this  maneuver. 


PERICARDITIS.  225 

Upon  the  rapidity  with  which  the  effusion  accumulates, 
and  upon  the  quantity  of  the  fluid,  depends  the  recognition  of 
pericardial  efi^usion.  It  is  manifest  that  rapid  distension  of 
the  pericardial  sac  may  produce  urgent  heart-symptoms ; 
whereas,  if  the  membrane  has  an  opportunity  to  adapt  itself 
to  a  gradual  stretching,  as  in  the  case  of  chronic  and  slowly 
accumulating  tuberculous  effusions,  cardiac  embarrassment  may 
not  arise.  Tuberculous  fluid  to  the  extent  of  a  quart  (1  1.)  or 
more  may  be  borne  with  surprising  comfort  on  the  part  of  the 
heart.  Cabot  states  that  less  than  5  ounces  (150  mils)  of  fluid 
are  seldom  recognized  at  the  bedside. 

Inspection  and  palpation  reveal  little  of  diagnostic  signifi- 
cance ;  the  third,  fourth,  and  fifth  intercostal  depressions  ad- 
jacent to  the  left  of  the  sternum  may  be  less  pronounced  than 
those  of  the  opposite  side.  The  cardiac  impulse  may  be  pres- 
ent when  the  patient  reclines  on  the  right  side,  for  the  reason 
that  gravitation  of  the  fluid  in  that  direction  causes  the  im- 
pulse to  reappear;  or  the  impulse  may  gradually  disappear  as 
the  fluid  accumulates.  Palpation  of  the  pulse  with  the  view  of 
detecting  gross  irregularities,  or  of  discovering  the  "pulsus 
paradoxus"  of  pericardial  effusion,  is  seldom  of  definite  value. 

Percussion  over  a  cardiac  effusion  elicits  an  increased  area 
of  cardiac  dullness,  usually  pear-shaped  and  extending  as 
high  as  the  second  rib  on  the  left.  The  dullness  extends 
abnormally  to  the  left,  and  on  the  right  obliterates  the  right- 
angle  dullness  of  the  cardiohepatic  junction.  It  is  to  be  re- 
membered that  the  effusion  may  change  in  location  with  a 
change  in  the  position  of  the  patient,  giving  us  shifting  areas 
of  cardiac  dullness.  A  dull  percussion  note  behind,  at  the  base 
of  the  left  lung,  first  described  by  Ewart,  is  a  valuable  cor- 
roborative sign  in  differential  diagnosis.  By  auscultation  a 
progressive  diminution  in  the  intensity  of  the  heart-sounds 
from  day  to  day  is  noted,  as  the  effusion  interposes  itself  be- 
tween the  heart  and  the  stethoscope.  Compression  of  the 
adjacent  lung  provokes  tubular  breathing,  increased  tactile 
fremitus,  and  bronchophony  in  the  compressed  and  atelectatic 
pulmonary  area. 

Adherent  Pericardium.  Systolic  retraction  of  the  tenth 
and  eleventh  left  interspaces  posteriorly — Broadbent's  sign — 
is  of  diagnostic  significance  in  adherent  pericarditis.     Smith's 


226      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

sign  is  also  of  strong  presumptive  import;  it  is  based  upon 
the  observation  that  the  impulse  of  a  normal  heart  has  an  ex- 
cursion of  one  or  two  inches  (2.5  or  5  cm.)  as  the  patient  lies 
upon  the  left  side,  and  upon  the  further  fact  that  the  cardiac 
impulse  descends  during  inspiration.  Such  excursions  are  not 
present  in  adherent  pericarditis,  and  the  cardiac  impulse  re- 
mains unchanged  in  position.  Fluoroscopic  examination  by 
the  Rontgen  rays  shows  a  restriction  in  the  up-and-down 
movements  of  the  heart  accompanying  breathing. 

TREATMENT. 

Absolute  rest — physical,  mental,  and  emotional — must  be 
strictly  enjoined,  in  order  to  insure  the  least  possible  degree 
of  cardiac  effort.  The  patient  is  permitted  that  posture  in 
bed  which  is  most  comfortable  to  him.  The  writers  are  out 
of  sympathy  with  the  theor\',  advocated  by  a  few,  that  early 
physical  effort  in  pericarditis  limits  the  area  of  pericardial 
adhesions  by  increasing  the  area  of  cardiac  excursion.  When 
one  considers  the  arh3-thmias  and  muscle  degenerations  ex- 
cited by  increasing  the  heart's  effort,  the  fallacy  of  such  a 
theory  is  at  once  apparent. 

Pain,  usually  due  to  myocardial  inflammation,  and  not  to 
the  pericardial  inflammation,  frequently  yields  to  the  applica- 
tion of  an  ice  bag  or  Leiter  coil  to  the  precordium ;  morphin 
in  %-gra.m  (0.0165  Gm.)  doses  h^^podermically  may  be  re- 
quired to  secure  rest.  In  the  stage  of  effusion,  blistering  of 
the  precordium  with  two  or  three,  seasoned  cantharidal  plas- 
ters, cut  in  squares  of  }i  inch  (6  mm.)  each,  often  give  gratify- 
ing results.  The  fly-blister  is  to  be  removed  as  soon  as  the 
vesicle  forms. 

Drug  therapy  is  limited  to  that  required  by  the  causative 
condition.  If  acute  rheumatic  fever  be  the  provocative  infec- 
tion, the  salicylates  are  used  in  a  daily  dose  of  perhaps  60  to 
120  grains  (4  to  8  Gms.)  ;  the  dose,,  however,  is  regulated  by 
the  effect  secured,  and  may  far  exceed  that  here  suggested. 
The  salicylates  are  usually  administered  with  sodium  bicar- 
bonate to  lessen  gastric  irritation.  Impending  cardiac  failure 
requires  cardiac  stimulants,  and  digitalis  in  supportive  dose, 
5  to  10  gtt.  (0.31  to  0.62  Gm.)  three  or  four  times  daily,  may 
be  indicated. 


PEKiCAUlJiTlS.  227 

As  to  the  suri^ical  treatment  of  pericardial  effusions,  it  is  to 
be  remembered  that  perhaps  the  majority  are  self-resolved 
under  proper  rest  and  treatment  of  the  causative  condition. 
When,  however,  no  such  tendency  is  shown  and  symptoms  of 
cardiac  embarrassment  are  added  from  day  to  day,  surgical 
intervention  is  to  be  considered.  Paracentesis  of  the  pericar- 
dium, according-  to  the  statistics  of  Mignon,  is  followed  by 
death  in  65  per  cent,  of  the  cases,  but  in  view  of  the  absence  of 
information  as  to  how  early  in  the  disease  this  operation  was 
performed,  we  should  not  permit  these  statistics  to  stay  our 
hand  in  employing  this  measure  for  relief  in  urgent  cases. 

If  the  patient  shows  signs  of  oppression,  and  physical  ex- 
amination corroborates  the  view  that  a  considerable  effusion 
is  present,  the  pericardium  should  be  tapped  and  the  fluid 
drained  off.  These  symptoms  are  blueness  of  lips  and  fingers ; 
rapid,  small,  compressible  pulse ;  great  dyspnea,  pulmonary 
congestion,  and  the  pulsus  paradoxus. 

The  pericardium  may  be  entered  in  one  of  several  locations. 
Usually  the  needle  is  passed  through  either  the  fourth  or  fifth 
interspace,  about  an  inch  (2.5  cm.)  to  the  left  of  the  left  border 
of  the  sternum.  The  right  cardiohepatic  angle  has  been  advised 
by  Rotch  as  the  best  site  for  the  operation.  Puncture  may 
also  be  made  in  the  fourth  or  fifth  interspace  to  either  side  of 
the  midclavicular  line,  or  the  third  and  fourth  interspace,  close 
to  right  border  of  sternum. 

In  any  event,  no  matter  what  site  is  chosen,  proceed  with 
the  greatest  caution,  bearing  in  mind  two  facts :  "one,  that  the 
diagnosis  may  not  be  correct;  and,  secondly,  that  even 
if  the  effusion  be  a  large  one,  the  heart  may  lie  close  to  the 
chest  wall. 

In  a  case  in  the  wards  of  the  Pennsylvania  Hospital,  Le 
Conte  removed  1700  mils  (55  f^)  of  seropurulent  fluid  from 
the  pericardium  by  means  of  a  puncture  made  in  the  fifth 
interspace,  just  outside  the  midclavicular  line.  The  proceed- 
ing was  as  follows :  After  cocainizing  the  skin,  a  small  in- 
cision was  made  of  size  just  sufffcient  to  prevent  catching  the 
ridge  of  the  trocar  in  the  skin,  an  incident  always  calling  for 
exertion  of  a  little  more  force  than  otherwise  would  be  needed, 
and  at  the  same  time  often  causing  the  sudden  release  of 
the    instrument,    and    the    consequent    plunging    it    in    more 


228      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

abruptly  and  more  deeply  than  necessary.  For  this  reason 
the  preliminary  incision  is  particularly  desirable  in  paracen- 
tesis of  the  pericardium.  The  trocar  was  introduced  through 
the  incision  and  carried  into  the  pericardial  cavity  by  means 
of  a  rotary  motion  combined  with  a  cautious  thrust. 

Fluid  should  be  withdrawn  slowly,  the  patient  watched 
for  collapse,  and,  if  it  appear  safe,  his  posture  may  be  changed 
to  the  upright,  in  order  thus  to  drain  ofT  more  fluid.  If  signs  of 
faintness  and  collapse  appear,  discontinue  the  operation  and 
give  a  stimulant,  such  as  camphorated  oil  hypodermically 
or  aromatic  spirits  of  ammonia  by  mouth.  Under  these  cir- 
cumstances, or  even  when  all  the  fluid  possible  is  withdrawn, 
it  is  sometimes  necessar}^  to  make  another  tap  because  of  its 
reaccumulation. 

If  the  fluid  does  not. become  purulent,  the  case  may  get 
well  slowly,  but  a  certain  amount  of  adhesions  are  likely  to 
form,  even  in  the  absence  of  pus. 

There. is  no  remedy,  either  in  the  way  of  drugs,  exercise, 
baths,  or  an^^  other  known  procedure,  that  can  prevent  the 
formation  of  such  adhesions,  and  their  effects  can  be  con- 
trolled in  about  the  same  measure.  During  convalescence, 
due  consideration  should  be  given  to  the  likelihood  of  a  more 
or  less  severe  myocarditis  having  accompanied  any  case  of 
pericarditis  with  effusion,  grave  or  mild. 

Following  convalescence,  prolonged  rest  and  mental  ease 
should  be  advised,  and,  for  those  who  can  afford  it,  travel. 

MYOCARDITIS. 

The  musculature  of  the  heart  may  be  subject  to  either 
acute  or  chronic  inflammatoiy  change.  Acute  infections 
of  the  endocardium  do  not  always  confine  their  activit}^ 
to  the  lining  membrane  of  the  heart,  but  may  readil}^  extend 
through  that  delicate  structure  to  the  contiguous  muscle-wall. 
While  acute  myocarditis  and  acute  endocarditis  arise  as  a  con- 
sequence of  infectious  processes,  3'et  they  do  not  always 
coexist,  nor,  on  the  other  hand,  can  a  diagnosis  of  one  be  made 
without  presupposing  the  coexistence  of  the  other  to  some 
degree. 


MYOCARDITIS.  229 

In  view  of  the  close  relationship  existing  between  myo- 
carditis and  endocarditis,  the  same  factors  are,  of  course, 
operative  in  the  production  of  either  condition.  Bacterial  in- 
vasion by  staphylococci,  streptococci,  the  Diplococcus  rheu- 
maticus  of  Poynton  and  Payne,  the  gonococcus,  and  the 
Klebs-Loflier  bacillus  are  examples  of  the  acute  infections 
that  induce  myocardial  damage.  Influenza,  is  an  increas- 
ingly common  cause  of  myocarditis.  The  specific  fevers  of 
typhoid,  scarlatina,  pneumonia,  and  the  hybrid  "rheumatic" 
group  are  to  be  carefully  watched  for  evidence  of  cardiac  im- 
plication. Conditions  such  as  Graves's  disease  (thyrotoxi- 
cosis), which  produce  rapid  and  long-continued  heart  action, 
may,  of  course,  induce  cardiac  exhaustion  and  subsequent 
myocardial  change.  Chemical  poisons,  among  them  alcohol, 
mercury,  lead,  and  arsenic  may  precipitate  acute  myocarditis, 
or,  when  long  continued,  induce  a  gradually  developed  chronic 
myocarditis.  The  effect  of  the  Spirocheta  pallida  upon  the  heart- 
muscle  of  the  syphilitic  should  not  be  lost  sight  of  as  an  etio- 
logic  factor. 

The  diagnosis  of  acute  myocarditis  is  more  a  matter  of 
deduction  than  a  question  of  physical  signs.  When,  in  the 
course  of  a  febrile  condition  due  to  bacterial  invasion,  we 
detect  an  irregularity  of  the  pulse  which  heretofore  has  shown 
but  the  change  of  increased  rate  and  volume ;  and  when  to 
this  is  added  a  sense  of  exhaustion  out  of  all  proportion  to  the 
severity  of  the  infection,  and  otherwise  unexplained,  myocar- 
ditis may  be  suspected.  The  detection  of  fine  rales  at  the  base 
of  the  lungs,  posteriorly,  oftener  occurring  on  the  more  de- 
pendent side,  owing  to  the  posture  of  the  patient,  is  a  valuable 
and  early  sign  of  myocardial  inefficiency.  Breathlessness, 
cyanosis,  pallor,  coldness,  faintness,  or  intense  prostration  ex- 
cited by  the  trivial  exertion  of  sitting  up  in  bed,  confirm  the 
suspicion.  Any  limitation  of  "the  field  of  cardiac  response" 
(Mackenzie)  in  either  the  bedridden  or  in  those  who  are  about 
the  affairs  of  daily  life  calls  for  a  prompt  investigation  of  the 
heart.  Precordial  pain,  or  pain  referred  to  the  neighborhood 
of  the  first  and  second  dorsal  ner\^es,  from  which  the  heart, 
developmentally,  receives  its  innervation,  may  furnish  an  addi- 
tional guide  to  the  recognition  of  the  condition.  Palpitation 
and  tachycardia  may  ensue.     An  increased  systolic  pressure, 


230       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

weak  and  irregular  heart-sounds  with  occasional  reduplication, 
systolic  murmurs  at  the  base,  and  evidences  of  cardiac  hyper- 
trophy, together  with  the  history  of  an  initial  infection,  fur- 
nish strong  presumptive  evidence  of  acute  myocarditis. 

The  incidence  of  abnormal  curves  in  an  electrocardiogram 
occurring  during  the  course  of  an  acute  infection  in  which 
there  had  previously  been  normal  records  is  a  diagnostic  point 
of  importance,  and  indicates  the  value  of  early  and  frequent 
electrocardiographic  examinations  during  the  progress  of,  and 
subsequent  to,  acute  infectious  disease. 

The  physician  who  fails  to  diagnose  acute  myocarditis  cor- 
rectly should  not  censure  himself  too  severely  for  his  lack  of 
diagnostic  acumen.  The  indefinite  and  variable  clinical  pic- 
ture, often  obscured  by  symptoms  of  the  initial  infection,  may 
often  cause  us  to  overlook  myocardial  change.  Cabot  is  re- 
sponsible for  the  statement  that  26  per  cent,  of  cases  of  fibrous 
myocarditis  are  found  post-mortem  which  had  not  been  diag- 
nosed during  life ;  that  52  per  cent,  of  the  cases  diagnosed  dur- 
ing life  were  not  found  post-mortem,  and  that  in  only  22  per  cent. 
did  the  clinical  diagnosis  and  autopsy  findings  agree. 

Chronic  myocarditis  may  exist  unrecognized  for  years  and 
may  be  first  observed  when  curtailment  of  accustomed  activi- 
ties draw  attention  to  the  heart.  Perhaps  one  in  middle  life 
suddenly  discovers  that  he  is  unable  to  spring-  up  the  staircase 
with  his  accustomed  agility ;  he  notices  breathlessness  and  a 
sense  of  constriction  about  the  chest  as  he  hurries  to  his  work ; 
faintness  and  dizziness  interrupts  his  ganie  of  golf ;  or  extreme 
exhaustion  and  palpitation  may  follow  the  stimulation  pro- 
duced by  motoring.  With  such  mild  limitations  of  the  field 
of  cardiac  response  does  failing  or  broken  compensation  first 
manifest  itself. 

Subsequent  Myocardial  Change  and  Prognosis.  Aside  from 
those  cases  of  myocarditis  which,  to  all  intent  and  practical 
purpose,  recover,  as  a  result  of  (1)  cardiac  resistance,  (2)  a 
limited  degree  of  infection,  or  (3)  through  early  recognition 
and  skillful  treatment,  myocarditis  is  essentially  progressive  in 
nature.  Rest,  so  necessar}-  to  a  restoration  of  normal  physical 
function,  is  a  therapeutic  measure  obtainable  only  to  a  modified 
degree  for  the  affected  heart;  complete  rest  is  impossible.  And 
so,  as  the  heart  labors  on,  cloudy  swelling  and  granular  degen- 


MVOCy\kL)ITIS.  231 

eration  may  affect  its  musculature ;  implication  of  the  coronary 
arteries  may  starve  the  cardiac  muscle  to  such  an  extent  that 
ischemic  atrophy  ensues.  Hyaline  and  fatty  degeneration  are 
rare  sequels  to  myocarditis ;  dissociation  of  one  muscle-cell 
from  another,  each  lying  separate  from  its  neighbor,  has  been 
observed  in  microscopic  studies  of  myocarditis. 

These  conditions  cannot  be  recognized  clinically,  and  are 
not  immediately  incompatible  with  life.  The  heart,  it  has  been 
determined  by  physiologists,  is'  capable  of  putting  forth  thir- 
teen times  the  effort  normally  required  to  maintain  the  body  at 
rest,  and  this  wonderful  reserve  power  is  not  readily  consumed. 
So  while  these  muscular  degenerations  are  not  incompatible 
with  life,  they  are  incompatible  with  longevity,  yet  may  per- 
mit an  existence  of  cardiac  invalidism  until  such  time  as  com- 
plete exhaustion  of  the  all-essential  heart-muscle  supervenes. 

Fibrous  increase  of  the  connective  tissue,  usually  distrib- 
uted irregularly  through  the  heart,  is  not  at  all  uncommon. 
Fatty  infiltration  of  the  subpericardial  connective  tissue  oc- 
curs very  frequently,  and  its  presence  is  often  suspected 
during  life  in  cardiac  patients  who  exhibit  a  general  tendency 
to  obesity.  Dyspnea  and  palpitation  are  symptoms  of  cardiac 
embarrassment  in  the  obese ;  and  muffled  heart-sounds  which, 
though  faint,  yet  bear  a  normal  relation  to  each  other  that  is 
like  a  distant  echo  of  themselves,  have  in  the  past  been  con- 
sidered sufficient  presumptive  evidence  for  the  once  popular 
diagnosis  of  ''fatty  heart." 

TREATMENT. 

Emphasis  should  first  be  laid  upon  the  value  of  securing  as 
much  rest  as  possible,  by  hygienic  and  dietetic  measures,  for 
the  damaged  heart-muscle.  If  the  physician  can  secure  a 
reduction  of  12  beats  per  minute  from  a  heart  rate  of  120, 
he  has  in  twenty-four  hours  saved  the  laboring  organ 
17,280  cycles;  in  other  words,  he  has  given  over  four  hours  of 
additional  rest  (diastole)  out  of  the  twenty-four  to  the  heart. 

The  indications  for  treatment  are  clear: 

1.  Rest — physical. 

2.  Rest — mental. 

3.  Rest — emotional. 

4.  Gentle  elimination. 


232      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

5.  Nutrition  of  the  heart  to  be  improved. 

6.  Symptoms  which   add   to  the   heart  load   should  be 

relieved. 

7.  Drugs  may  be  required  to  sustain  the  heart. 

1.  The  patient  should  at  once  be  put  at  complete  rest  in  bed. 
While  this  may  seem  too  arbitrary  a  ruling  for  a  given  case, 
it  is  much  easier  to  lessen  restrictions  as  individual  circum- 
stances ma}^  require,  rather  than  to  impose  added  restrictions 
upon  a  patient  whom  we  have  permitted  to  be  ambulant.  As 
the  symptoms  improve,  the  libert)^  of  the  room  or  house  may 
be  allowed.  The  period  of  confinement  to  bed  is  usualh-  con- 
tinued until  a  normal  rate  and  rhythm  of  pulse  ensues,  at- 
tended by  the  disappearance  of  other  cardiac  symptoms,  with 
no  unfavorable  signs  manifestirig  themselves  on  a  change  of 
posture.  Judgment,  of  course,  dictates  that  the  aged  and  the 
infirm,  who  bear  bed  confinement  poorh^,  shall  be  permitted 
a  limited  amount  of  liberty,  of  which  limit  they  are  often  the 
best  judges,  rather  than  to  be  fretted  and  worried  by  the  loss 
of  appetite,  insomnia,  and  mental  depression  attendant  upon 
arbitrary  curtailment  of  their  mode  of  life. 

2.  That  mental  rest  is  of  no  less  importance  than  physical 
rest  is  strikingly  demonstrated  by  the  beneficial  results  of 
sanatorium  treatment.  There  the  head  of  a  household  is 
freed  from  the  worr}^  of  conducting  or  superintending  the 
home,  rid  of  the  vexations  of  servants,  awa^^  from  the  intru- 
sions of  oversolicitous  friends,  and  is  amid  quiet,  rest-inducing 
surroundings,  where  the  ear  is  not  strained  to  catch  every 
unusual  noise  in  the  house,  nor  the  mind  kept  busily  em- 
ployed interpreting  each  sound. 

3.  Emotional  disturbances  are  difficult  to  guard  against  in 
the  home-management'  of  a  cardiac  patient,  and  they  have  a 
profound  influence  upon  the  heart.  The  attentions  of  well- 
meaning  nurses  may  irritate ;  the  sympathetic  eye  of  a  friend 
ma}^  cause  depression  of  spirits ;  a  whispered  voice  may  be 
interpreted  as  ominous,  or  a  laugh  mistaken  for  an  utter  lack 
of  feeling.  In  many  such  ways  the  emotions  of  a  patient  may 
be  played  upon,  and,  through  the  sympathetic  nerve-fibers, 
actually  affect  the  heart. 

4.  Gentle  elimination  is  a  term  that  is  advisedly  used.  Mild 
laxatives,  such  as  fluidextract  of  cascara  sagrada  or  moderate 


MYOCARDITIS.  233 

doses  of  the  salines,  used  at  frequent  intervals,  are  to  be 
chosen  in  preference  to  drastic  cathartics  which  deplete  the 
system  and  add  the  burden  of  physical  exhaustion  to  the  labor- 
ing heart.  For  the  same  reason,  vigorous  diuretics  and  the 
induction  of  free  perspiration  are  to  be  avoided.  A  satisfac- 
tory diuretic  in  those  cases  where  the  non-employment  of 
digitalis  makes  a  diuretic  advisable  is: 

IJ  Spiritus  astheris  nitrosi   ilss   (16.0  mils). 

Syrupi   f3ij   (8.0  mils). 

Liquor  potassii  citratis  ..q.  s.  ad  fSiij  (90.0  mils). 
M.  Sig. :  Teaspoonful  (3.75  mils)  in  a  little  cold 
water  at  two  or  three  hour  intervals  until  effective. 

The  use  of  electric-light  or  other  superheated  cabinets  may 
prove  very  exhausting  to  the  myocardiac ;  the  skin  can  usually 
be  kept  freely  eliminative  by  tepid  sponging,  followed  by 
witchhazel  massage.  The  urgent  incidence  of  uremia  may,  of 
course,  demand  hot  packs;  the  occurrence  of  apoplexy  will 
necessitate  prompt  and  vigorous  catharsis;  but  these  are  ex- 
ceptional instances  in  the  usual  management  of  myocardial 
disease. 

5.  Improving  the  nutrition  of  the  heart  may  be  accomplished 
indirectly  by  easing  the  load,  and  by  increasing  the  period  of 
cardiac  rest,  as  pointed  out  above.  As  to  the  direct  effect  of 
foods  upon  the  heart-muscle  itself,  much  yet  remains  to  be 
discovered.  The  specious  statement  that  "a  diseased  heart 
requires  more  nourishment  than  a  healthy  one"  is  at  direct 
variance  with  the  universal  principles  of  diet  in  disease,  where 
an  effort  is  made  to  regulate  protein  intake  as  well  as  quan- 
tity of  food.  A  cardiac  patient  who  is  at  rest  in  bed  or  con- 
fined to  his  room  manifestly  requires  less  nourishment  than 
when  up  and  around ;  consequently,  he  must  reduce  the  intake 
of  food  if  he  would  avoid  overloading  kidneys,  bowels,  and 
liver,  and  by  remote  effect  on  these  organs  indirectly  aggra- 
vate the  condition  of  the  heart  and  circulation.  Small  quanti- 
ties of  nutritious  food  at  frequent  intervals,  the  limiting  of 
protein  intake,  and  the  elimination  from  the  dietary  of  foods 
productive  of  intestinal  fermentation  in  a  given  case  are  safer 
rules  to  follow  than  is  the  blind  adoption  of  one  of  the  many 
"cardiac  diets."  When  it  has  been  shown  that  these  selected 
diets  add  length  to  the  numbered  days  of  the  advanced  heart 


234      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

case,  and  when  it  has  been  shown  that  this  increase  of  days 
was  not  attained  by  a  sacrifice  of  appetite,  and  by  proscriptions 
of  dietary  that  made  the  extra  days  of  life  seem  not  worth 
while,  then,  and  only  then,  can  cardiac  diets  be  said  to  have 
added  to  our  therapeutics. 

One  notable  exception  to  the  general  impracticability  of 
rigid  food-regulation  in  cardiac  patients  is  the  diet  suggested 
by  Karrell  to  be  used  when  it  is  desirable  to  limit  the  water 
intake,  which,  by  increasing  an  existing  edema,  ascites,  or 
pleural  effusion,  adds  to  the  embarrassment  of  the  heart.  An 
initial  aspiration  of  ascitic  fluid  or  of  the  pleural  transfusion, 
should  either  be  present,  affords  a  degree  of  relief  to  the  labor- 
ing heart,  and  the  beneficial  effect  is  maintained  by  instituting 
a  diet  which  limits  fluid  intake  to  the  nourishment  found  in 
milk ;  the  free  use  of  salt  is  interdicted  for  the  reason  that  it 
accumulates  in  the  tissues  and  attracts  fluids  to  the  parts. 
Even  sufficient  salt  to  maintain  the  normal  individual  demand 
of  15  grains  (1  Gm.)  per  day  is  prohibited  at  first,  until  the 
excess  previously  stored  in  the  tissues  may  be  considered  ex- 
hausted.   The  Karrell  diet  is  as  follows : 

For  the  first  seven  days,  8  ounces  (200  mils)  of  milk  at  8 
and  12  a.m.;  4  and  8  p.m.     No  other  food  or  fluid. 

Eighth  day,  milk  as  above,  and  at  10  a.m.  1  soft-boiled  egg ; 
at  6  p.m.  2  pieces  of  dry  toast. 

Ninth  day,  milk  as  above,  and  at  10  a.m.  and  6  p.m.  1  soft- 
boiled  egg  and  2  pieces  of  dry  toast. 

Tenth,  eleventh,  and  twelfth  days,  milk  as  above,  and  at  12 
noon  chopped  meat,  rice  boiled  in  milk,  and  vegetables;  6  p.m., 
1  soft-boiled  egg. 

No  salt  is  used  throughout  the  course.  Salt-free  toast 
and  butter.  Small  amount  of  cracked  ice  with  diet.  All  meat 
can  often  be  advantageously  omitted.^ 

Cane-sugar  in  Heart  Disease.  The  classic  experiment  of  F. 
S.  Locke, 10  in  which  he  demonstrated  that  the  excised  heart 
of  a  rabbit  could  be  kept  pulsating  for  four  days  by  pouring 
through  it  a  solution  containing  dextrose,  has  stimulated  much 
interest  in  the  clinical  value  of  sugar  as  a  means  of  nourishing 
depraved  heart-muscle.  Physiologists  have  discovered  that 
the  sinoauricular  node,  the  bundle  of  His,  and  its  arboriza- 
tions, contain  a  remarkable  amount  of  glycogen.     Prof.  Dr. 


MYOCARDITIS.  235 

Adamkiewiezll  states  that  the  heart  requires  its  own  weight 
of  sugar  each  day  for  its  nourishment  (9  to  11  ounces — 254  to 
312  Gm.).  These  observations  have  been  utiHzed  by  Sir 
Arthur  Goulston,  of  Exeter,  in  the  treatment  of  heart  disease 
with  cane-sugar  (he  carefully  avoiding  the  employment  of 
beet  and  other  sugars),  yielding  brilliant  results.  He  be- 
gins with  the  administration  of  2  ounces  (56.6  Gm.)  a  day, 
pushing  the  administration  rapidly  to  4  ounces  (113  Gm.)  a 
day,  or  even  to  10  ounces  (283  Gm.)  in  some  instances.  The 
likelihood  of  digestive  disturbances  and  intestinal  fermenta- 
tion is  disposed  of  by  the  observation  of  Abderhaldeni-  that 
the  lactic  acid  ferment  of  the  intestines  does  not  attack  cane- 
sugar  or  milk-sugar. 

6.  Symptoms  which  add  to  the  heart  load,  and  which  the 
physician  may  have  to  ameliorate,  are :  anasarca,  pain,  sleep- 
lessness, constipation,  hepatic  torpor,  dyspnea,  bronchitis,  and 
vomiting.  Where  possible,  remedial  measures  other  than 
drugs  should  be  employed.  Dropsical  effusions  may  be  re- 
lieved by  the  trocar  and  cannula;  painful  engorgement  of  the 
extremities  by  Southey's  tubes  or  multiple  punctures  (3/^  inch 
— 10  mm,  deep)  of  the  tense  and  edematous  skin,  always  under 
antiseptic  precautions  and  with  subsequent  aseptic  dressing; 
pain  may  be  amenable  to  the  ice-bag  or  hot  fomentations ; 
sleep  may  be  induced  by  hot  drinks,  by  massage  or  friction 
rubs;  constipation  and  hepatic  torpor  frequently  yield  to  a 
diet  of  laxative  foods  or'enemata ;  dyspnea,  to  a  change  in  posi- 
tion, or  the  use  of  oxygen ;  bronchitis,  to  the  gradual  improve- 
ment of  the  cardiac  condition ;  and  vomiting,  to  a  temporary 
withdrawal  of  all  foods  by  the  mouth,  save  the  sipping  of  ice- 
water,  and  to  the  counterirritant  efl'ect  of  mustard  plasters  (1 
part  mustard,  5  parts  flour)  applied  to  the  epigastrium. 

7.  Drug  therapy  in  myocarditis,  save  for  the  emergencies 
arising  in  connection  with  the  cardiac  arhythmias,  is  limited 
principally  to  the  employment  of  digitalis  and  its  congeners. 
The  indication  for  its  employment  is  either  a  failure  to  improve 
in  tone  or  else  a  progressive  zveakening  of  the  cardiac  muscle 
when  the  simpler  forms  of  treatment  already  outlined — rest, 
elimination,  etc. — are  ineffective.  The  large  dram-a-day  dose 
of  the  tincture  is  seldom  required;  8  or  10  drops  (0.5  to  0.62 
mil)   three  times  a  day  are  quite  often  sufficient.     The  drug 


236      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

will  be  withdrawn  when  the  desired  effect  is  produced.  Digi- 
talis, it  is  to  be  remembered,  distinctly  increases  myocardial 
irritability  and  raises  blood-pressure  by  slowing  and  increas- 
ing the  force  of  the  ventricular  contraction. 

Strophanthus  and  squill  are  cardiac  tonics  that  are  used 
when  digitalis  fails.  Caffein,  theobromin,  and  convallaria 
are  employed  in  the  milder  cases,  when  a  temporary  change 
of  drugs  is  advisable.  The  rapid,  diffusible  stimulant,  aro- 
matic spirit  of  ammonia,  is  at  times  of  temporary  service. 
Strychnin  finds  its  best  employment  not  in  the  treatment  of 
the  cardiac  condition,  but  when  combined  with  iron,  arsenic, 
or  quinin,  in  building  up  the  general  nutrition  of  the  patient 
during  convalescence.  In  this  connection,  while  we  hold  no 
brief  for  any  manufacturing  pharmacists,  believing  that  pre- 
scriptions should  be,  for  the  most  part,  specifically  adapted  to 
the  individual  case,  we  feel  that  we  might  well  draw  attention 
to  a  constant  and  dependable  preparation  of  strychnin  and 
iron,  which  latter  drug  is  not  permitted  to  oxidize  during  the 
process  of  manufacture,  and  which  gives  uniform  results. 
We  refer  to  "Tabloid  Blaud,"  consisting  of  carbonate  of  iron, 
5  grains  (0.324  Gm.)  ;  arsenic  %oo  grain  (0.00065  Gm.),  and 
strychnin  sulphate,  34oo  grain  (0.00065  Gm.).  The  carbonate 
of  iron  does  not  react  until  it  reaches  the  stomach,  in  strong 
contrast  with  many  inert  "Blaud"  preparations  on  the  market. 
The  convenience  of  an  iron  preparation  that  is  stable  will  be 
appreciated  by  the  physician  who  is  obliged  to  dispense  his 
own  remedies,  as  will  also  the  form  of  administration,  which 
guards  against  the  definitely  determined  deleterious  action  of 
iron  when  it  comes  in  contact  with  the  teeth. 

The  A"-ray  has  a  therapeutic  value  in  myocarditis,  due  to 
excessive  glandular  activity,  such  as  is  exemplified  in  Graves's 
disease,  or  exophthalmic  goiter,  the  Rontgen  light  reducing  the 
activity  of  the  gland,  and  thus  lessening  the  quantity  of  toxins 
set  free  to  act  injuriously  upon  the  heart, 

ENDOCARDITIS. 

Inflammation  of  the  lining  membrane  of  the  heart  arises  as 
a  complication  of,  or  as  a  sequel  to,  acute  infections  occurring 
within  the  body.     On  account  of  its  frequent  association  with, 
the  symptoms  of  septic  absorption,  and  as  a  result  of  the  ob- 


ENDOCARDITIS.  237 

servations  that  the  condition  more  usually  occurs  as  a  sequel 
to  rheumatic  fever,  tonsillitis,  and  chorea,  the  misleading 
term  "rheumatism  of  the  heart"  is  sometimes  applied  to  endo- 
carditis. The  term  should  be  discarded.  It  gives  no  clear 
conception  of  the  condition,  and  may  utterly  misdirect  the 
treatment  of  the  physician  who  relies  upon  "antirheumatic 
drugs"  to  correct  the  perverted  cardiac  condition. 

When  one  considers  the  influence  of  febrile  conditions 
upon  the  circulation,  which  frequently  raise  the  rate  from  8 
to  10  beats  a  minute  for  each  additional  degree  of  fever,  the 
probability  of  infection  of  the  overworked  heart  by  disease 
germs  already  actively  engaged  in  elaborating  toxins  in  other 
parts  of  the  body  become  quite  manifest.  Among  the  bacteria 
detected  in  the  endocardium  at  autopsy  are  streptococci, 
staphylococci,  the  Diplococcus  rheumaticus,  gonococci,  Klebs- 
Loffler  bacilli,  and  the  bacillus  of  Koch.  The  condition  may 
also  arise  in  connection  with  specific  fevers,  such  as  pneu- 
monia, scarlatina,  diphtheria,  and  enteric  fever. 

Depending  upon  the  virulence  of  the  initial  disease,  upon 
the  resistance  of  the  heart  to  infection,  and  upon  its  ability 
to  withstand  the  labor  imposed  upon  it,  acute  endocarditis 
may  develop  into  the  malignant  form.  There  is  no  well-de- 
fined line  of  demarcation  between  the  two ;  nor  can  too  fine 
a  distinction  be  drawn  between  that  point  where  either  variety 
evolves  itself  into  chronic  endocarditis  (valvular  disease  of 
the  heart)  ;  the  difference  is  but  a  difference  of  degree.  It 
should  be  borne  in  mind  that  we  are  not  always  able  to  trace 
a  history  of  antecedent  infection,  and  that  acute  endocarditis 
may  seem  to  arise  as  the  consequence  of  an  infection  of  the 
heart  alone,  with  apparently  no  other  organs  implicated. 

The  left  heart  presents  the  more  constant  pathologic 
change,  the  area  of  the  mitral  valve  showing  endothelial  de- 
generation ;  next  in  frequency  the  aortic  cusps  are  infected. 
Roughened  valve-surfaces  become  the  seat  of  fibrin  deposits 
whipped  from  the  blood-stream,  these  vegetations  frequently 
being  infected  and  swept  as  emboli  to  other  parts  of  the  body. 
Coincident  with  thickening  of  the  cusps,  or  with  the  formation 
of  vegetations,  retraction  of  the  leaflets  may  occur,  giving  rise 
in  life  to  the  murmurs  which  often  first  direct  attention  to  the 
presence  of  endocarditis. 


238      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

Morbid  changes  do  not  invariably  affect  the  valves;  they 
are  not  confined  to  the  endocardium  alone ;  the  myocardium 
and  pericardium  may  be  affected,  constituting  a  pancarditis. 
Especially  is  this  true  in  the  streptococcic  heart  affections  of 
children. 

This  disease  presents  no  definite  clinical  signs  by  which 
we  may  detect  its  presence.     Its  recognition  depends  upon 


Fig.  14. — Malignant  endocarditis,  with  extensive  implication  of 
aortic  valves  (Philadelphia  General  Hospital).  (From  Da  Costa's 
Physical  Diagnosis.     Copyright,  W.  B.  Saunders  Co.) 


the  astuteness  of  the  medical  attendant  who  correlates  the 
variable  symptom-complex ;  the  diagnosis  is  rarely  found  in 
the  admission  records  of  hospitals.  The  suspicions  of  the 
clinician  are  aroused  when,  in  the  course  of  an  acute  infectious 
disease,  he  detects  irregularity  in  the  volume  and  rhythm  of 
a  pulse  previously  having  shown  no  variance  other  than  an 


ENDOCARDITIS.  239 

increase  of  rate.  An  elevation  of  temperature  unusual  for  a 
given  disease,  or  showing-  a  persistence  beyond  that  ordinarily 
encountered,  and  which  cannot  be  otherwise  satisfactorily  ex- 
plained, should  call  for  detailed  and  frequent  examinations  of 
the  heart.  A  leucocytosis  out  of  proportion  to  an  existing  ar- 
thritis, tonsillitis,  chorea,  or  a  persistently  high  leucocyte 
count  following  these  conditions,  may  point  to  endocarditis. 

The  occurrence  of  cardiac  murmurs  where  none  had  pre- 
viously existed,  and  the  tendency  of  these  murmurs  toward 
■daily  variations  of  both  location  and  intensity,  are  most  sig- 
nificant. Usually  they  are  heard  at  the  mitral  area,  and  are 
systolic  in  time,  indicating  regurgitation ;  during  the  period  of 
valve-roughening  they  may  be  of  a  musical  quality.  Mitral 
murmurs  are  observed  with  marked  frequency  in  choreic  pa- 
tients. Concomitant  hypertrophy  of  the  heart  may  exist.  The 
occurrence  of  embolic  occlusion  of  an  artery  is  of  diagnostic 
significance  in  endocarditis. 

The  less  complicated  form  of  acute  endocarditis,  which 
does  not  develop  to  the  degree  of  malignancy,  is  usually  not 
fatal.  The  patient  may  recover  entirely,  or  receive  the  heri- 
tage of  a  "damaged  heart,"  which  eventuates  in  chronic  val- 
vular disease.  In  the  malignant  form,  where  the  lining  mem- 
brane of  the  heart  shares  its  damage  with  the  myocardium,  or 
where  septic  thrombi  are  whirled  to  other  portions  of  the 
body,  the  outcome  is  a  question  of  profound  gravity. 

TREATMENT. 

It  is  of  vital  importance  that  absolute  rest  in  bed  be  insisted 
upon.  The  patient  with  either  acute  or  malignant  endocar- 
ditis is  not  permitted  even  to  turn  himself  from  one  side  to 
another,  until  the  symptoms  subside;  bed-pans  and  urinals 
save  physical  effort  and  thus  conserve  cardiac  strength. 
When  we  reflect  that  an  affected  heart  which  makes  8  extra 
beats  a  minute  makes  11,520  cycles  a  day  more  than  are  re- 
quired in  health,  we  can  then  appreciate  the  absolute  necessity 
of  sparing  the  organ  even  such  a  demand  as  would  be  occa- 
sioned by  the  effort  of  extending  the  hand.  We  should  remem- 
ber, too,  that  increased  heart-rates  are  usually  at  the  expense 
of  the  rest-period  of  each  cycle.  More  effort  means  more  ex- 
haustion ;  more  exhaustion  means  less  resistance  of  the  cardiac 


240      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

tissues  already  affected,  and  a  consequent  extension  of  the 
inflammation. 

The  physician  who  presents  the  necessity  of  rest  to  a  pa- 
tient in  a  manner  that  causes  alarm  is  temperamentally  unfor- 
tunate. Instructions  should  be  given  to  the  nurse,  thus 
sparing  the  patient  the  added  burdens  of  anxiety,  alarm,  or 
depression. 

The  hygienic  indications  of  elimination  are  met  as  re- 
quired. Gentle  catharsis  is  secured  by  fluidextract  of  cascara 
sagrada  in  10-  to  30-  drop  (0.6  to  1.8  mil)  doses,  effect- 
ively meets  the  indication  of  peristaltic  stimulation,  and 
avoids  an  unwished-for  depletion  of  bodily  fluids  with  the 
larger  and  sometimes  nauseating  doses  of  salines.  The  nurse 
will  emplo}^  tepid  baths,  followed  by  witchhazel  rubs,  to  keep 
the  skin  in  active  condition ;  the  kidneys  are  stimulated  with 
small  but  frequentlv  repeated  drinks  of  water  to  which  fruit 
juices  mav  be  added.  Diet  is  of  the  form  most  readily  assim- 
ilable and  is  free  from  any  substance  which,  by  provoking  in- 
digestion or  fermentation,  may  add  to  the  load  of  the  heart. 
J\lassage,  if  employed  in  the  acute  stage,  must  be  most  intel- 
ligently directed;  pain  and  coldness  in  an  extremity,  arising 
as  a  consequence  of  an  embolus  having  lodged  in  the  peri- 
pheral circulation,  may  cause  a  well-meaning  nurse  to  massage 
the  part  with  no  thought  of  the  possibility  of  friction  breaking 
up  and  further  distributing  the  infarct.  Heat  ma}^  be  em- 
ployed to  relieve  the  sensory  disturbances  caused  by  an  em- 
bolus ;  opiates  may  be  required  for  pain.  Insomnia,  which  is 
the  bitterest  antagonist  of  our  much-sought-for  rest,  should  be 
controlled  by  quiet  surroundings,  well-ventilated  chambers, 
and  by  the  employment  of  opiates  in  sufficient  dosage  to  se- 
cure the  results  desired. 

The  next  step  in  treatment  is  directed  to  the  removal  of 
the  underhnng  cause.  If  acute  rheumatic  fever  be  the  provo- 
cative infection,  the  salicylates  are  employed  in  10-  to  20- 
grain  (0.66  to  1.32  Gm.)  doses  at  three-  or  four-  hour  inter- 
vals— always  sufficiently  diluted,  and  alwa3'S  combined  with 
equal  doses  of  sodium  bicarbonate,  for  the  purpose  of  prevent- 
ing gastric  irritation,  and  in  the  hope  of  preventing  the  pos- 
sible Dccurrence  of  salicylate-poisoning  bv  thus  rendering  the 
urine  alkaline.     The  physician  may  have  to  abandon  the  use 


ENDOCARDITIS.  241 

of  the  salicylates  in  order  to  spare  the  stomach — a  step  which 
he  will  promptly  take  upon  the  appearance  of  gastric  irrita- 
tion or  other  evidences  of  disordered  digestion. 

Chorea  is  treated  by  the  administration  of  liquor  potas- 
sii  arsenitis  (Fowler's  solution),  beginning  with  3-drop  (0.18 
mil)  doses,  well  diluted  in  water,  t.  i.  d.,  p.  c.  The  dose  is 
increased  1  drop  (0.06  mil)  at  each  administration,  until  the 
physiologic  limits  of  arsenical  tolerance  become  manifest  by 
slight  puflfiness  under  the  eyes,  looseness  of  the  bowels,  and 
griping.  When  these  symptoms  occur,  the  drug  is  withdrawn 
for  a  day  or  two,  and  its  administration  again  begun  in  a 
daily  decrease  of  dose  until  a  minimum  of  5  drops  (0.31  mil) 
t.  i.  d.  is  reached,  and  then  increased  as  before. 

Autogenous  vaccines  {i.e.,  vaccines  derived  from  that  par- 
ticular variety  of  germs  present  in  a  given  case,  as  determined 
by  bacteriologic  examination  and  cultures  from  the  blood, 
causative  abscesses,  etc.)  may  be  required;  and  when  used 
should  be  used  early.  Laboratory  delays  in  securing  an 
autogenous  vaccine  may  require  the  employment  of  "stock" 
(already  prepared  and  marketed)  vaccines  until  the  more 
desirable  autogenous  serum  can  be  obtained.  As  to  the  efficacy 
of  this  form  of  treatment  much  doubt  exists — a  doubt  which 
entitles  the  patient  to  the  benefit  occasionally  reported  in  en- 
docarditis from  its  employment. 

Further  steps  in  the  treatment  of  endocarditis  arising  in- 
dependent of  specific  fevers  (which  are  treated  according  to 
the  indications  for  each),  of  course,  embrace  an  unremitting 
search  for  suppurative  foci  in  tonsils,  at  the  apices  of  teeth, 
in  ear  involvements,  gall-bladder  infections,  perirenal  ab- 
scesses, cutaneous  affections,  cystitis,  pyelitis,  and  bone  or 
joint  involvements. 

Cardiac  weakness  may  require  tincture  of  digitalis  in  5-  to 
10-drop  (0.31  to  0.62  mil)  doses  at  four-  or  five-  hour  inter- 
vals. It  is  not  to  be  used  as  a  routine,  but  only  to  meet 
indications  of  cardiac  muscular  weakness  or  compensatory 
failure. 

Convalescence.  The  duration  of  the  rest-period  in  those 
patients  who  have  passed  through  acute  or  malignant  endocar- 
ditis is  one  of  profound  importance.  It  is  to  be  continued 
until  all  symptoms  have  disappeared,  and  until  the  rate  and 

16 


242      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

rhythm  of  the  pulse  are  normal.  The  patient  may  then  be 
permitted  to  sit  up  for  a  brief  interval,  which  is  gradually 
lengthened  as  the  days  pass,  and  as  no  unfavorable  change  in 
the  area  of  cardiac  dullness  or  rate  and  rhythm  of  the  pulse 
ensue.  This  usually  means  six  or  eight  weeks  in  bed,  and  an- 
other month  on  a  couch,  before  any  activity  is  resumed. 

The  physician  who  thoroughly  appreciates  the  pathology 
of  the  soft  and  infiltrated  valves  in  acute  endocarditis,  and  the 
possibility  of  resolution  terminating  in  scar-formation  on  the 
leaflets  by  ill-advised  exertion,  will  hesitate  to  assume  any 
responsibility  for  the  probable  chronic  valvular  disease  which 
may  be  caused  by  a  disregard  of  the  essential  element  of  rest. 

VALVULAR    DISEASE. 

Clinical  Pathology.  Rate  of  Heart-heat.  Under  normal 
conditions  the  pulse-rate  and  heart-rate  are  equal,  and  the 
beats  occur  at  about  72  per  minute  in  an  adult. 

The  rate  is  influenced  by  exertion,  food,  certain  kinds  of 
drinks,  such  as  cofifee  and  alcohol,  and  by  various  diseases. 
Fevers,  certain  toxic  states,  such  as  Graves's  disease,  chronic 
valvular  and  myocardial  change,  may  and  do  increase  the  rate 
above  the  normal. 

The  rate  may  be  persistently  above  normal,  or  may  be 
so  only  at  intervals ;  and  a  different  significance  attaches  to 
the  symptom  because  of  the  constant  or  fugitive  quality  of 
the  change. 

Thus,  a  persistently  rapid  rate  of  the  heart-action  suggests, 
in  the  absence  of  any  of  the  causes  just  enumerated,  a 
chronic  valvular  or  myocardial  change,  and  a  heart  that  is 
trying  to  make  up  by  haste  for  M^hat  it  lacks  in  power. 

An  occasionally  rapid  pulse,  particularly^  if  it  be  very  rapid, 
suggests  a  change  of  a  rather  inexplicable  nature  associated 
with  paroxysmal  tachycardia  and  auricular  flutter  or  fibrilla- 
tion, which  conditions  are  dealt  with  more  fully  under  Arhy- 
thmia  {v.s.).  A  too  rapid  pulse  after  slig"ht  exertion,  and 
a  failure  to  return  to  the  normal  rate  within  a  short  time, 
afford  to  a  slight  extent  an  index  of  the  cardiac  reserve  force. 

A  slozv  pulse  is  more  uncommon  than  a  rapid  one,  and 
yet  there  are  occasional  instances  of  slow  pulse  consistent 
with  health. 


VALVULAR    DISEASE.  243 

Slow  pulse  is  seen  occasionally  in  brain  tumor,  meningitis, 
and  jaundice.  It  is  also  met  with  in  cases  of  aortic  stenosis,  al- 
though by  no  means  is  this  a  constant  occurrence,  and  in  cer- 
tain forms  of  cardiac  disturbances,  where  the  pulse-rate  is  not 
a  true  indication  of  the  heart-rate. 

For  instance,  in  cases  in  which  the  auricular  beats  may 
be  very  frequent,  mariy  of  the  impulses  are  not  conveyed 
to  the  ventricle ;  and  again  a  certain  number  of  these  im- 
pulses may  be  responded  to  but  feebly  by  the  ventricle,  with 
the  result  that  no  pulse  impression  is  carried  to  the  palpating 
finger. 

Premature  systoles  may  cause  an  apparent  slowness  of  the 
heart's  action,'  as  shown  by  an  examination  of  the  pulse  alone, 
while  heart  block  in  which  the  auricles  and  ventricles  are  beat- 
ing with  little  or  no  relation  to  one  another,  causes  a  real 
slowing  of  the  ventricle. 

Valvular  and  Muscular  Disease,  It  is  rather  a  common  view 
that  unless  there  are  very  evident  signs  of  disease  of  the  heart 
there  is  no  serious  ailment.  The  presence  of  a  loud  murmur, 
signs  of  great  enlargement  of  the  heart,  pulsation  of  the  pre- 
cordia  and  vessels  of  the  neck,  and  attacks  of  angina 
or  general  anasarca  are  alone  the  indications  of  gravity  in 
heart  cases,  according  to  views  held  more  or  less  generally. 

It  is  necessary,  however,  in  order  to  arrive  at  an  intelli- 
gent prognosis,  to  consider  a  great  many  other  factors,  some 
of  which  are  at  first  apparently  but  trivial,  but  which,  when 
considered  together,  and  dovetailed  into  proper  relation  with 
the  history  of  the  case,  may  prove  of  greater  value  toi  a  cor- 
rect understanding  of  the  state  of  the  heart  and  its  reserve 
force  than  the  presence  o£  the  more  evident  and  more  easily 
recognized  signs. 

Valvular  disease  may  or  may  not  be  serious,  according  to 
the  condition  of  the  heart-muscle  and  its  reserve  force,  which 
latter  may  be  regarded  as  an  individual  attribute,  and  therefore 
hard  to  compute  in  concrete  terms. 

The  effects  of  a  diseased  heart  valve  are  too  well  known  to 
need  much  explanation  in  detail. 

The  diseases  of  the  valves  give  rise  to  stenosis  or  regur- 
gitation, as  the  case  may  be,  or  to  both  conditions  in  one  and 
the  same  valve. 


244      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

To  overcome  this  defect  in  orifice  or  valve,  and  to  keep  up 
the  circulation  and  supply  the  needed  nutriment  to  the  tissues 
of  the  body  and  the  heart-muscle  itself,  the  organ  is  compelled 
to  do  more  work  than  it  does  under  normal  conditions. 

This  is  accomplished  in  most  cases  in  a  greater  or  less 
time  bv  the  development  of  dilatation  and  hypertrophy. 
Dilatation  of  a  chamber  of  the  heart  is  a  necessity  in  over- 
coming the  diminution  of  the  amount  of  blood  in  circula- 
tion as  a  result  of  a  valvular  lesion.     In  other  words,  if  there 


Normal 


Fig.  15. — Comparative  sizes  of  the  ventricles  in  a  normal  and 
a  h3'pertrophied  heart  (Philadelphia  General  Hospital).  (From 
Da  Costa's  Physical  Diagnosis.    Copyright,  W.  B.   Saunders  Co.) 

is  a  back  leak  in  a  valve,  a  greater  amount  of  blood  must  be 
held  in  the  propelling  cavity  to  compensate  for  the  inevitable 
loss  when  the  contraction  takes  place. 

Granted  that  this  be  true,  hypertrophy  becomes  a  natural 
corollary  in  a  muscularly  healthy  heart,  the  muscle  tissue  en- 
larging to  do  the  extra  work  of  discharging  from  the  cavity  a 
greater  amount  of  blood  than  normal  in  practically  the  same 
time-  as  is  granted  the  normal  heart  to  discharge  its  lesser 
quantity. 

In  the  event  that  a  ventricle — for  that  is  the  cavity  most 
commonly  affected  in  valvular  disease — is  not  able  so  to  take 


VALVULAR    DISEASE.  245 

care  of  a  lesion  of  the  valve,  an  explanation  may  lie  in  the 
fact  that  the  heart-muscle  itself  may  have  heavily  shared  in 
the  attacks  upon  the  endocardium,  and  been  rendered  unfit 
to  carry  on  its  part  of  a  handicapped  function. 

There  is  a  great  difference  between  this  kind  of  dilatation 
and  that  which  comes  on  in  the  course  of  a  chronic  heart 
lesion,  associated  with  dropsy  and  the  long-  train  of  symptoms 
connected  with  general  heart-failure. 

Mackenzie,  taking  as  a  basis  the  functions  ascribed  by 
Gaskell  to  the  heart-muscle,  makes  a  strong  and  convincing 
argument  that  dilatation  of  the  heart — a  cause  of  heart-failure 
in  the  valvular  cases — is  due  to  the  failure  of  one  of  the  par- 
ticular muscle  functions,  namely,  tonicity. 

For  instance,  he  quotes  cases  where  the  muscle  tissues  of 
the  ventricle  had  become  so  worn  and  thin  that  rupture  had 
taken  place,  and  A^et  neither  before  nor  after  death  was  dila- 
tation apparent.  And  with  these  instances  account  must  be 
taken  of  high  pressures  and  constant  effort,  even  to  the  rup- 
ture-point ;  but  the  mystery  of  the  function  of  tonicity  remains 
quite  as  dark  as  the  formerly  accepted  theory  of  muscle 
exhaustion. 

There  are  instances  of  sudden  cardiac  failures  and  deaths 
in  those  who  show  no  muscular  nor  valvular  heart  disease, 
where  certainly  none  of  the  phenomena  that  are  part  and  par- 
cel of  the  customary  changes  incident  to  cardiac  failure  ac- 
cording to  the  exhaustion  and  back  pressure  theory  are 
evident. 

At  the  same  time  no  one  will  claim  that  failure  of  an  im- 
portant muscular  function  of  the  heart  takes  place  in  a  heart- 
muscle  free  from  disease  or  exhaustion,  and  certainly  our  in- 
ability to  demonstrate  such  change  is  because  of  ignorance 
and  not  because  of  the  lack  of  evidence. 

The  action  of  the  heart,  according  to  the  recent  views,  is 
dependent  upon  the  integrity  of  the  cardinal  functions,  already 
spoken  of,  and  to  the  co-ordination  of  these  functions  as  well. 
It  is  likely  that  a  failure  in  one  of  these  functions  will  upset 
the  others  to  the  extent  of  causing-  serious  heart  embarrass- 
ment or  death. 

The  generally  accepted  view  of  the  progressive  steps  lead- 
ing to  cardiac  failure  is  much  as  follows : 


246      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

The  leakage  from  a  valve  causes  dilatation  and  hyper- 
trophy ;  the  extra  amount  of  work  and  strain  thereby  provoked 
in  the  effort  to  keep  up  circulation  leads  to  the  hypertrophy 
and  dilatation  of  the  chamber  next  adjacent,  and  so  on  until 
the  right  heart  and  tricuspid'  valves  fail,  with  the  appearance 
of  congestion  of  the  liver  and  general  dropsy. 

At  any  rate,  whether  or  not  the  change  be  directly  due  to 
muscular  exhaustion,  to  back  pressure,  or  to  failure  of  an  arbi- 
trarily assumed  function  of  the  cardiac  muscle,  dilatation  is 
usually  associated  with  heart-failure  as  a  cause. 

The  treatment  of  heart  conditions  arising  from  damage 
and  partial  destruction  of  a  valve  or  of  several  valves,  in  no 
wise  differs  from  the  treatment  of  heart-failure  from  other 
causes  except  as  regards  the  etiologic  factor  at  work,  which 
to  some  extent  may  be  controlled. 

The  fact  of  the  existence  of  a  heart-murmur,  the  evidence 
of  a  valvular  disease,  does  not  per  se  call  for  any  treatment 
whatever,  but  rather  for  advice  as  to  the  proper  mode  of  life 
to  be  pursued  in  order  to  prescribe  to  the  utmosti  the  reserve 
force  of  the  heart,  and  to  make  so  little  demand  upon  it  as  to 
leave  the  patient  with  a  comfortable  margin  in  time  of  need. 

As  has  been  said  before,  the  treatment  of  any  condition 
of  heart-failure  must  be  based  upon  a  study  of  the  muscular 
condition,  and  must  be  directed  with  a  view  to  resting,  conserv- 
ing, and  relieving  the  strain  or  infection  from  which  this 
muscle  suffers.  It  must  be  borne  in  mind  that  overtreatment 
may  do  harm  in  heart  disease  as  in  other  states,  and  that  it  is 
only  when  there  are  clear  indications  for  treatment  that  any 
drugs  of  other  methods  should  be  employed. 

As  intimated  above,  there  is  some  difference  in  the  treat- 
ment from  the  point  of  view  of  the  etiology.  Thus,  the  treat- 
ment of  a  heart  condition  resulting  from  an  acute  infective 
process,  such  as  rheumatism  or  septicemia,  naturall}^  differs 
from  that  due  to  an  active  syphilitic  process,  as  in  each  case 
the  cause  of  the  disease  demands  active  specific  treatment. 

This,  however,  is  largely  aside  from  the  question  of  the 
treatment  of  the  actual  heart-failure  itself,  and  here,  whether 
this  be  due  to  valvular  disease  caused  by  rheumatism,  or  to 
sclerotic  processes  of  old  age  and  syphilis,  the  problem  is  the 
same,  and  is  centered  in  the  muscular  tissues. 


VALVULAR    DISEASE.  247 

Pathologic  Physiology  of  Valvular  Disease.  Without  go- 
ing into  the  question  of  the  minute  pathology  of  endocar- 
ditis, it  is  sufficient  here,  for  the  purposes  of  rational  and 
understanding  treatment,  to  consider  the  results  of  the  inflam- 
mation of  the  endocardium  present  and  remote. 

A  large  percentage  of  endocarditis — almost  all  cases  in  the 
young — are  due  to  rheumatism,  chorea,  and,  to  a  less  degree, 
scarlet  fever.  Those  diseases  confined  to  the  aortic  valve  in 
adult  and  later  life  are  due  to  syphilis  and  sclerotic  processes 
of  advanced  life.  Many  authors  hold  that  hard  physical  labor 
is  a  frequent  cause  of  aortic  disease. 

Curiously  enough,  a  great  many  cases  of  mitral  stenosis, 
even  in  the  young,  give  no  history  of  any  of  the  infectious 
diseases  so  common  in  their  association  with  valvular  heart 
disease. 

Endocarditis,  be  it  from  what  cause  it  may,  causes  a 
thickening",  roughening,  and  shrinkage  of  the  valves,  and  in 
some  cases  a  sclerotic  change  at  the  orifices,  which  result  in 
a  narrowing  of  the  opening  affected.  This  latter  condition, 
spoken  of  as  stenosis,  or  obstruction,  is  often  a  progressive 
lesion,  advancing  either  with  moderate  rapidity  or  very  slowly 
indeed.  In  the  case  of  stenosis  of  the  mitral  orifice,  where  it 
has  become  extreme,  the  valve  as  such  ceases  to  exist,  and  in 
its  place  is  found  a  diaphragm  formed  by  fusion  of  the  leaflets 
covering  the  whole  auriculo-ventricular  orifice,  with  a  mere 
slit  for  an  opening,  and  where  from  the  nature  of  things  it  is 
apparent  that  no  valve  function  any  longer  exists. 

Whether  the  endocarditis  and  resulting  changes  be  of  the 
nature  of  a  regurgitation  or  an  obstruction,  the  heart  at  once 
suffers  from  a  handicap,  and  is  obliged  to  do  more  work  in  a 
given  time  than  formerly,  and  to  do  this  work  dilates  and 
hypertrophies  according  to  its  strength  and  nutrition,  and  the 
result  is  what  is  commonly  spoken  of  as  a  compensated  heart. 

By  this  we  understand  that  the  heart  has  sufficient  reserve 
force  to  respond  to  the  needs  of  the  circulation,  although  called 
upon  for  more  than  usual  exertion. 

For  the  time,  then,  the  patient  is  to  all  intents  and  pur- 
poses as  well  as  a  person  with  healthy  valves,  save  for  the 
fact  that  he  is  not  able,  or  could  not  be  able  for  long,  to  stand 


248      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

as  much  work  as  the  healthy  man,  because  of  the  necessary 
encroachment  on  his  reserves. 

There  are  many  factors  that  have  to  do  with  the  length 
of  time  a  heart  disease  caused  by  a  valvular  lesion  may  con- 
tinue without  causing-  symptoms. 

One  thing,  however,  is  certain,  and  that  is  that  no  drugs 
will  benefit  the  valve  itself,  and  that  the  patient  will  not  out- 
grow the  disease.  The  valve  disease  will  last  as  long  as  the 
patient;  and  in  most  cases,  unless  an  intelligent  mode  of  living 
be  adopted,  the  disease  will  rapidly  outgrow  the  patient's 
strength  and  reserve  force,  and,  in  the  case  of  the  young,  con- 
sign them  to  an  early  grave. 

The  question  of  the  ultimate  breakdown  of  the  heart  and 
the  consequent  heart-failure  has  already  been  gone  into  at 
some  length  under  the  caption  of  ^Myocarditis.     (See  p.  228.) 

Whether  this  heart-failure  be  due  to  back  pressure  or  to 
failure  of  tonicity  makes  no  difterence  as  far  as  the  treatment 
is  concerned. 

The  actual  degree  of  incompetence  or  of  obstruction  must 
be  considered  in  determining  the  probable  duration  of  life  of 
a  patient  suftering  from  valvular  disease ;  also  the  mode  of 
life ;  temperament ;  the  susceptibility  to  rheumatism,  ton- 
sillitis, etc. ;  the  infecting  cause ;  the  ability  to  control  syphilis 
or  arteriosclerosis,  if  present ;  and  the  personal  equation  of 
the  patient's  inherent  strength  and  resistance,  formerly  spoken 
of  as  his  constitution. 

So  far  the  valvular  diseases  have  been  spoken  of  as  a  whole 
rather  than  as  individual  conditions,  because  of  the  fact  that 
the  failing  heart-muscle,  and  not  the  valve  demands  treatment. 
As  regards  prognosis,  however,  there  is  a  difference  in  respect 
of  the  valve  or  valves  aff'ected. 

Simple  mitral  regurgitation  may  be  regarded  as  the  least 
serious  of  valvular  lesions,  and  aortic  regurgitation  and  mitral 
stenosis,  in  their  order,  next.  " 

Tricuspid  disease  is  rarely  seen  except  as  a  condition 
secondar}^  to  one  of  the  other  lesions,  while  pulmonary  dis- 
ease is  almost  invariably  congenital. 

Aortic  regurgitation  is  most  frequently  associated  with 
sudden  death,  often  when  the  patient  has  been  entirely  un- 
conscious of  the  existence  of  any  cardiac  trouble  whatever. 


VALVULAR    DISEASE.  249 

This  it  is  that  makes  it  imperative  that  the  physician  should 
warn  a  patient  of  this  possibility,  particularly  if  he  follows  a 
hazardous  occupation. 

Relatively  common  is  the  association  of  mitral  stenosis 
with  embolism.  The  prognosis  of  valvular  disease  is  more  un- 
favorable when  more  than  one  valve  is  involved,  and  favor- 
able or  not  according  to  the  tractability  of  underlying  causes, 
and  associated  changes  in  vessels,  kidneys,  and  liver. 

This  with  the  implied  condition  that  the  patient  himself  is 
seconding  the  physician  in  his  advice  as  regards  mode  of  life 
and  medication. 

Congenital  Valvular  Defects.  These  consist  of  alterations 
in  valves,  septa,  and  ducts.  In  many  instances  the  child 
dies  at  birth  or  shortly  after,  as  often  the  condition  will  not 
permit  of  life. 

These  alterations  may  be  due  to  endocarditis  in  utero,  or 
to  congenital  defects  in  development. 

From  the  point  of  view  of  the  therapeutist  there  is  not  a 
great  deal  to  be  said,  as  the  victims  of  these  conditions  rarely 
live  a  great  while,  with  the  exception  of  those  who  suffer  from 
pulmonary  valvular  conditions,  which  are  likely  to  allow  of 
longer  life. 

The  heart  may  be  misplaced,  either  to  the  right  side  of  the 
chest,  or  actually  be  an  abdominal  organ. 

The  auricular  or  ventricular  septum  may  be  incomplete, 
and  as  a  consequence  there  may  be  large  gaps  between  the 
two  cavities. 

The  foramen  ovale  may  remain  patent,  with,  in  some  cases, 
but  slight  disturbance. 

There  may  be  various  anomalies  of  the  valves,  particularly 
the  pulmonary  and  aortic,  and  to  a  lesser  degree  at  the  other 
sites.  Supernumerary  and  rudimentary  valves  are  sometimes 
found. 

In  a  case  in  the  author's  wards  at  the  Pennsylvania  Hos- 
pital, the  pulmonary  artery  itself  was  stenosed.  No  valves 
could  be  found  at  the  pulmonary  orifice,  but  a  number  of  small 
rudimentary  valve  formations  were  found  at  irregular  inter- 
vals in  the  first  few  centimeters  of  the  pulmonary  artery. 
This  patient  was  an  adult. 


250      DISEASES    OF    THE    CARDIO\'ASCULAR    SYSTEM. 

Pulmonary  stenosis  is  the  most  common  congenital  lesion 
that  may  call  for  treatment,  and  this  in  no  wise  differs  from 
that  of  an  acquired  condition  which,  because  of  heart-failure, 
calls  for  appropriate  measures. 

Mitral  Regurgitation.  This  is  the  commonest  of  the  val- 
vular lesions,  and  may  also  be-  regarded  as  the  least  harmful. 
By  this  is  meant  that  an  ordinarily  incompetent  mitral  valve 
is  less  harmful  than  incompetence  of  a  like  degree,  say,  in  the 
aortic  valve.  This  comparison  is  more  theoretic  than  real,  as 
it  is.  impossible  to  measure  the  degree  of  incompetence  of  a 
valve  with  any  great  accuracy,  even  at  autops}^,  but  the  truth 
of  the  statement  is  generally  accepted  as  a  result  of  experience. 
IMitral  insufficiency  may  exist  alone,  or  may  be  associated  with 
other  valvular  lesions,  either  at  the  mitral  orifice  or  at  other 
sites. 

A  certain  amount  of  obstruction  may  be  present,  due  to 
thickening  of  the  valves  and  to  deposits  in  and  about  the  mitral 
ring. 

Furthermore,  mitral  regurgitation  may  be  slowly  replaced 
by  pure  obstruction,  because  of  gradual  contraction  of  cica- 
tricial tissue.  It  is  hard  to  believe  that  there  is  any  such 
thing  as  obstruction  without  regurgitation,  though  it  is  un- 
questionable that  to  all  intents  and  purposes  marked  stenosis 
is  a  condition  by  itself,  and  any  regurgitation  which  may  take 
place  is  so  inconsiderable  as  to  be  ignored. 

The  characteristic  physical  signs  of  mitral  regurgitation  are 
a  soft  svstolic  apical  murmur,  usually  transmitted  toward  the 
left  axilla,  accentuation  of  the  pulmonic  second  sound,  and 
bilateral  ventricular  enlargement. 

The  murmur,  usualty  soft,  may  be  harsh,  loud,  or  quite 
short  or  long,  and  but  little  signiticance  can  be  attached  to 
anv  of  these  characteristics. 

The  murmur  is  not  alwa5^s  transmitted,  and  frequentty  in 
very  grave  cases  it  is  so  localized  as  to  be  difficult  of  discovery 
unless  the  stethoscope  is  placed  directly  at  the  apex.  Some- 
times in  the  case  of  a  heart  that  quickly  changes  in  size — that 
is,  either  dilates  or  overcomes  a  dilatation  in  a  few  hours — a 
wrong  conclusion  that  a  given  murmur  has  disappeared  may 
be  arrived  at  because  of  not  carefully  following  the  change  in 
the  apex  position,  and  thereby  failing  to  hear  a  murmur  heard 


VALVULA]>^    DISIiASE.  251 

but  a  few  hours  previously.  Mitral  murmurs  with  thrills  in- 
dicate valvular  lesions,  and  contraindicate  mere  dilatation 
from  loss  of  tonicity. 

The  advent  of  a  mitral  murmur,  coincident,  or  nearly  so, 
with  cardiac  failure  indicates  a  dilatation  and  functional  in- 
capacity of  the  ring. 

It  is  not  necessary  here  to  go  further  and  discuss  the  symp- 
toms of  heart-failure  associated  with  mitral  regurgitation, 
as  such  symptoms  are  common  to  all  valvular  lesions,  and  are 
in  reality^  but  those  of  the  muscular  failure,  the  relation  of 
which  to  valvular  disease  already  has  been  emphasized. 

Mitral  Stenosis.  This  condition  is  the  most  interesting  of 
all  the  valvular  lesions,  and  in  its  proper  understanding  lies 
the  key  to  the  comprehension  of  the  other  derangements. 
Furthermore,  there  are  several  distinct  stages  of  the  disease 
which  offer  widely  diiTerent  physical  signs,  and  unless  the 
rationale  of  their  production  be  understood,  it  is  difficult  to 
apply  treatment  intelligently. 

Mitral  stenosis  is,  of  course,  as  is  well  known,  more  com- 
mon in  women  than  in  men,  and  is  found  with  great  fre- 
quency in  those  who  give  no  previous  rheumatic  history.  It 
is  also  quite  frequently  a  progressive  lesion,  although  there  are 
marked  exceptions  to  this  where  cases  go  along  quite  well 
for  many  years  without  great  disability,  although  often  with  a 
very  rapid  and  irregular  heart,  of  which  they  may  not  be 
conscious. 

On  the  other  hand,  after  a  certain  stage  is  reached,  there  is 
no  class  of  cases  in  which  an  early  and  oft  repeated  break- 
down may  be  more  surely  prophesied  than  in  advanced  mitral 
stenosis.  Hospital  cases,  in  those  who  are  compelled  to  make 
their  living  by  manual  labor,  return  again  and  again,  in  one 
to  two  or  three  weeks'  time,  although  after  a,  short  rest  in  bed, 
and  the  administration  of  digitalis,  compensation  is  readily 
established.  The  social  service  worker  here  is  a  most  neces- 
sary adjunct  to  the  physician. 

Another  peculiarity  of  mitral  stenosis  is  the  absence  of 
general  dropsy,  which  in  a  measure  can  be  explained  by  the 
fact  that  the  strain  falls  largely  on  the  pulmonary  circula- 
tion rather  than  on  the  systemic,  as  long  as  the  right  ven- 
tricle holds  out. 


252      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

Cases  of  mitral  stenosis  are  particularly  prone  to  hemo- 
ptysis, and  in  the  absence  of  a  murmur  are  not  infrequently 
mistaken  for  tuberculosis  and  only  after  a  careful  elimination 
of  lung"  disease  is  the  true  nature  of  the  case  recognized. 

The  physical  signs  of  mitral  stenosis  vary  with  the  degree 
of  auricular  force.  Broadbent  has,  with  a  great  deal  of  reason, 
divided  the  condition  into  three  stages,  for  all  of  the  symp- 
toms of  which  he  gives  appropriate  and  convincing  physio- 
logic reasons. 

The  first  stage  is  characterized  by  the  presence  of  a  pre- 
systolic murmur,  followed  by  a  first  and  second  sound  of  the 
heart.  The  murmur  is  of  a  peculiar,  low  crescendo  type,  and 
comes  right  up  to  and  ends  abruptly  with  the  first  sound  of 
the  heart.  A  presystolic  thrill  is  also  present,  usually  felt  just 
inside  and  above  the  apex  beat. 

The  murmur  is  deep  in  tone,  and  vibratory,  and  indeed, 
when  one  is  well  acquainted  with  heart  conditions,  no  effort 
at  timing  of  the  murmur  is  needed,  as  its  quality  is  path- 
ognomonic. 

It  is  perhaps  easier  also  to  time  by  the  tactile  sense  than 
by  the  auditory,  and  the  thrill  can  be  most  easily  recognized 
as  preceding  the  apex  beat. 

There  is  no  hypertrophy  of  the  ventricle — or  but  little — 
at  this  or  at  any  other  time,  except  in  those  cases  where  there 
is  mitral  regurgitation,  or  a  lesion  at  the  aortic  orifice. 

There  is,  however,  hypertrophy  of  the  right  ventricle  and 
dilatation  of  the  left  auricle. 

In  this  stage  there  should  be  little  or  no  difificulty  in  mak- 
ing a  diagnosis,  and  also,  while  the  conditions  remain  as 
described,  the  patient  will  suffer  no  discomfort  or  danger. 

The  second  stage,  according  to  Broadbent,  is  characterized 
by  the  disappearance  of  the  second  sound  at  the  apex,  and 
by  an  altered  character  of  the  first  sound,  which  loses  its  nor- 
mal muscular  tone  and  becomes  short,  sharp,  and  loud,  and 
more  like  a  second  sound  than  a  first.  The  apex  beat  is  of  a 
quality  that  might  be  expected — rather  abrupt  and  slapping, 
and  devoid  of  thrust. 

This  is  almost  as  characteristic  as  a  murmur  or  thrill,  and 
in  man}^  instances,  from  palpation  of  the  apex  beat  alone,  this 
lesion  may  be  recognized. 


VALVULAR    DISEASE.  253 

It  is  in  this  stage  that  mistakes  in  diagnosis  frequently 
occur.  Two  sounds  are  heard  which  commonly  are  wrongly 
interpreted  to  be  first  sound  with  murmur  followed  by  second 
sound,  and  a  diagnosis  of  mitral  regurgitation  is  established. 

The  absence  or  enfeeblement  of  the  second  sound  is  the 
cause  of  the  confusion,  and  the  peculiar  deep-toned  quality 
of  the  murmur,  which  should  give  the  clue,  misleads  the  ob- 
server into  the  belief  that  he  is  listening  to  a  first  sound. 

The  third  stage  is  characterized  by  the  disappearance  of 
the  presystolic  murmur,  and  at  this  time  great  irregularity  is 
sure  to  ensue,  although  the  patient  may  have  no  decided  sys- 
temic disturbance. 

The  disappearance  of  the  murmur  is  believed  by  Broadbent 
to  be  due  to  the  giving  way  of  the  tricuspid  valve,  but  it  is 
now  much  more  certain  that  the  cause  lies  in  the  existence  of 
auricular  fibrillation,  and  the  consequent  inadequacy  'of  the 
auricular  systole. 

There  are,  of  course,  many  other  interesting  features  of 
this  most  interesting  cardiac  condition,  but  these  fundamen- 
tal facts  are  sufficient  for  a  work  on  treatment  alone. 

Aortic  Regurgitation.  Aortic  regurgitation  is  quite  com- 
monly of  syphilitic  origin,  particularly  when  occurring  alone, 
and  is  in  the  valvular  lesion  most  commonly  the  cause  of  sud- 
den death. 

It  is  characterized  by  a  diastolic  murmur  heard  at  the 
aortic  cartilage,  and  ofen  audible  with  at  least  equal,  or  even 
greater,  intensity  at  the  third  left  cartilage. 

The  pulse  is  very  characteristic  in  many  cases,  and  pistol- 
shot  sounds  may  be  heard  in  the  arteries  in  some  cases,  par- 
ticularly in  the  young,  or  in  those  who  developed  the  disease 
when  still  young. 

The  regurgitant  murmur  is  sometimes  heard  most  dis- 
tinctly at  the  apex,  where  also  a  presystolic  murmur  described 
by  Flint,  is  audible.  This  bruit  is  due  to  the  impinging-  on  the 
mitral  valves  of  the  blood-currents  leaking  back  through  the 
incompetent  aortic  leaflets. 

A  systolic  aortic  murmur  is  practically  always  present 
when  there  is  aortic  regurgitation,  though  it  may  not,  and 
usually  does  not,  signify  the  presence  of  concomitant  stenosis. 


254      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

Rather  is  it  due  to  roughness  and  rigidity  of  the  valves  over 
which  the  blood-current  flows. 

Very  great  hypertrophy  is  seen  in  aortic  regurgitation, 
and  a  patient  may  have  a  huge  bovine  heart  for  years  without 
being  conscious  of  it,  in  spite  of  taking  part  in  games  calling 
for  violent  exercise. 

Angina  pectoris  is  more  commonly  seen  in  aortic  disease 
than  in  disease  of  other  valves,  and  rupture,  at  all  times  a 
rare  condition,  more  frequently  afifects  the  aortic  valves  than 
any  of  the  others. 

Two  observations  confirmatory  of  aortic  regurgitation  are 
found  in  the  employment  of  the  sphygmomanometer.  Aus- 
cultation reveals  that  the  loud  systolic  "rap"'  does  not  disap- 
pear at  the  point  expected,  but  persists  as  the  dial  falls  to 
zero.  Again,  when  the  patient  is  prone,  the  systolic  pressure 
when  the  cuff  is  applied  to  the  leg  is  found  to  be,  perhaps, 
1^4  inches  (30  mm.)  higher  than  when  the  observations  are 
made  with  the  cuff  on  the  arm. 

Aortic  Stenosis.  The  murmur  of  aortic  stenosis  is  systolic 
in  time,  localized  at  the  aortic  cartilage,  and  conducted  into 
the  vessels  of  the  neck;  it  is  accompanied  by  a  systolic  basic 
thrill,  enfeeblement  of  the  aortic  second  sound,  and  moderate 
hypertrophy  of  the  left  ventricle,  or  no  demonstrable  enlarge- 
ment of  this  chamber  whatever.  The  heart  is  likely  to  be  slow, 
and  the  pulse  lingering.  The  patient  is  prone  to  attacks  of 
.vertigo  and  unconsciousness  due  to  fainting. 

Tricuspid  regurgitation  is  frequently  a  sequel  to  heart-fail- 
ure in  association  with  any  of  the  valvular  conditions ;  it  may 
be  congenital,  or  acquired  from  rheumatic  or  other  infections. 

This  murmur  is  systolic  in  time,  and  is  heard  with  greatest 
intensity  over  the  middle  and  lower  half  of  the  sternum. 

The  valve  is  scarcely  competent  at  best,  and  very  readily 
gives  way  under  back  pressure,  whereupon  symptoms  of  pul- 
monary distress  appear,  and  blueness  of  face  and  extremities, 
dropsy,  and  pulsating  liver  rapidly  follow. 

Mackenzie  points  out  that  often,  in  spite  of  great  incom- 
petence of  the  tricuspid  valve,  no  murmur  at  all  is  heard,  yet 
the  truth  of  its  existence  is  proven  by  the  pulsating  liver  and 
the  ventricular  type  of  liver  and  jugular  pulsations. 


ANGINA    PECTORIS.  255 

Tricuspid  Stenosis.  Tricuspid  stenosis  is  seen  in  connec- 
tion with  mitral  stenosis  at  times,  and  usually  is  not  recog- 
nized either  if  alone  or  if  a  lesion  of  the  mitral  valve  also  be 
present. 

Broadbent  believes  that  it  is  to  be  assumed  that  tricuspid 
stenosis  has  developed  in  cases  of  mitral  stenosis  with  great 
anasarca. 

Lesions  of  the  pulmonary  orifice  or  valves  are  usually 
congenital.  A  pulmonary  stenosis  may  be  caused  by  the  pres- 
sure of  an  aneurysm. 

ANGINA    PECTORIS. 

Angina  pectoris  literally  means  "pain  of  the  breast,"  and 
the  term  is  applied  to  a  symptom-complex  consisting  of  (1) 
paroxysmal  attacks  of  substernal  pain,  commonly  radiating  to 
and  down  the  left  arm ;  (2)  a  sense  of  constriction  within  the 
thorax;  (3)  a  feeling  of  impending  dissolution.  These  symp- 
toms may  be  present  in  a  given  case  in  greater  or  less  degree, 
and  any  one  of  the  three  may  be  totally  absent. 

There  are  recognized  anginoid  conditions  to  which  are 
given  the  title  of  "pseudoangina,"  which  are  to  be  distin- 
guished from  true  angina.  These  occur  in  neurasthenic 
or  hysteric  individuals,  and  should  be  readily  recognized, 
though  sometimes  the  distinction  is  not  easy.  Occasionally 
true  angina  pectoris  has  been  mistaken  for  the  attacks  of  pain 
common  to  acute  indigestion.  If  the  identity  of  any  partic- 
ular attack  be  in  doubt,  it  is  better  to  err  on  the  side  of  the 
graver  malady,  and  to  treat  the  patient  accordingly,  until  the 
correct  diagnosis  is  established. 

Angina  pectoris  is  frequently  observed  among  the  elderly 
and  in  the  prematurely  aged,  due  to  the  existence  of  arterial 
change  and  to  alteration  of  the  myocardium.  An  increasing- 
incidence  is  noted  in  the  period  of  mature  development,  be- 
tween the  ages  of  35  and  50,  at  which  time  the  provocative 
aortic,  coronary  or  cardiac  damage  wrought  by  chronic  infec- 
tions reveals  itself. 

Angina  pectoris  is  of  infinitely  more  frequent  occurrence  in 
males  than  in  females.  Statistical  studies  are  most  interestine" 
in  this  connection ;  Husband's  237  cases  give  us  an  incidence 


256       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

of  60  men  to  1  woman ;  Forbes  presents  88  cases  showing-  a 
frequency  of  10  men  to  1  woman ;  Benvenkel's  report  of  117 
cases  states  the  male  frequency  at  7  to  1 ;  Osier's  40  cases 
included  only  1  woman. 

The  chief  causes  of  angina  pectoris  are  sclerotic  changes 
in  the  aorta,  coronary  arteries,  and  myocardium  incident 
to  the  advance  of  years,  and  the  result  of  chronic  infections. 
It  is  probable  that  the  myocardial  changes  are  of  at  least 
as  great  etiologic  importance  as  those  in  the  coronary  vessels, 
as  many  cases  have  gone  through  life  without  any  attacks  of 
angina  and  yet  autopsy  has  disclosed  most  severely  damaged 
coronary  arteries.  A  not  unlikely  view  is  that  the  attacks  are 
precipitated  by  temporary  ischemia  of  the  heart-muscle,  be- 
cause of  its  inability  to  adjust  its  circulating  power  to  a  sud- 
den demand,  such  as  may  follow  physical  exertion,  emotion, 
or  shock. 

Next  in  frequency  to  the  "senile  heart"  as  an  etiologic 
factor,  syphilis  plaj^s  an  important  role.  The  statistics  of 
Warthin,  of  Ann  Arbor,  referred  to  under  Aneurysm  in 
this  chapter,  indicate  the  amazing  incidence  of  aortic  selec- 
tion exhibited  by  the  Spirocheta  pallida.  We  do  not  believe 
that  the  pernicious  activity  of  the  treponema  is  confined  to 
the  aorta  alone,  and  venture  the  opinion  that  future  re- 
searches will  reveal  its  extension  to  the  contiguous  coronary 
arteries  and  heart-muscle,  and  establish,  statistically,  the  role 
assumed  by  S3^philis  as  a  frequent  factor  in  angina  pectoris. 
Nor  is  it  too  much  to  expect  that  further  investigations  by 
syphilographers  will  explain  the  frequent  association  of  aortic 
insufficienc)?-  with  angina  pectoris. 

Gout,  obesity,  diabetes,  profound  mental  and  emotional 
disturbances,  acute  infections,  and  the  toxic  effect  induced  by 
drugs  are  classicalh^  enumerated  as  causes  of  angina.  Coffee, 
tea,  and  alcohol  as  probable  causes  may  be  ruled  out  by  a  two- 
month  abstinence  from  the  suspected  indulgence. 

The  pain,  the  constriction,  and  the  anguish  mentioned  in 
our  definition  require  no  further  elaboration  here,  other  than 
the  succinct  description  given  by  Seneca  of  his  own  case : 
"The  attack  is  verj^  short  and  like  a  storm.  It  usually  ends 
within  an  hour.  To  have  any  other  malady  is  only  to  be  sick ; 
to  have  this  is  to  be  dying." 


ANGINA   PECTORIS.  257 

Dyspnea  is  rare;  the  respi/atory  movements  may  be  shal- 
low, but  seldom  are  they  urgent.  The  pulse  is  not  often 
altered  from  its  pre-existing  condition.  Systolic  elevations  of 
blood-pressure  are  not  at  all  constant  in  the  clinical  picture, 
and  are  as  frequently  absent  as  present  during  an  attack. 
The  complexion,  as  a  rule,  is  at  first  flushed,  then  pale ;  pro- 
fuse perspiration  is  to  be  expected  in  this  anguishing  malady. 

Physical  signs,  apart  from  those  of  concomitant  conditions, 
are  absent.  The  characteristic  pulse  and  infiltrated  blood- 
vessels of  arteriosclerosis  may  be  observed,  as  may  also  a 
systolic  pulsation,  due  to  a  dilated  aorta  in  the  second  inter- 
space, to  the  rig-ht  of  the  sternal  border;  an  increased  area 
of  aortic  dullness  due  to  the  same  cause,  may  be  elicited;  but 
these  are  not  physical  signs  of  angina  pectoris :  they  are  in- 
dicative only  of  associated  conditions. 

Guarded,  not  necessarily  fatal,  is  the  prognosis  of  this 
affection,  the  course  of  which  is  dependent  upon  the  degree  of 
exhaustion  of  the  heart-muscle.  In  young-  subjects,  or  in  those 
acute  attacks  that  are  induced  by  toxic  agents  apparently 
complete  recovery  may  ensue.  Sclerotic  hearts  with  fair  car- 
diac reserve  force  may  live  throug-h  many  years  of  successive 
attacks ;  while  a  weakened  myocardium,  with  no  demonstrable 
lesion,  may  succumb  early  after  the  establishment  of  the 
malady.  These  incidents  are  to  be  well  considered  in  arriving 
at  an  estimate  of  life  expectancy,  which  must  be  based  upon 
the  cardiac  reserve  force,  and  upon  the  opportunities  afforded 
for  its  conservation, 

TREATMENT. 

More  latitude  in  the  questions  of  rest  and  exercise  may  be 
permitted  in  angina,  pectoris  than  in  any  other  circulatory 
malady.  The  exhaustion  attendant  upon  a  severe  attack  of 
"stenocardia"  may,  of  course,  necessitate  convalescence  in 
bed ;  attacks  induced  by  exposure  to  cold  may  demand  that 
the  patient  be  confined  to  his  room ;  in  advanced  myocardial 
degeneration,  the  conser^^ation  of  every  ounce  of  energy  may 
demand  absolute  curtailment  of  physical  activities.  The 
physician  must  be  guided  in  his  opinion  in  these  matters 
solely  by  a  careful  consideration  of  each  individual  case,  re- 
membering that,  as  a  g^eneral  rule,  confinement  is  better  borne 


258       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

by  the  young,  but  often  results  in  undesirable  conditions  in 
the  aged.  Exercise,  is  limited  to  a  slow  and  steady  gait  on 
level  surfaces,  avoiding  cardiac  strain.  Emotional  stress, 
anxieties,  mental  concentration,  and  depression  of  mind  are 
to  be  avoided.  Diet  is  to  be  regulated ;  and,  in  so  far  as  is 
possible,  the  indigestible  foods  that  may  induce  intestinal  dis- 
orders or  gastric  derangements  are  to  be  curtailed.  Especially 
is  this  precaution  necessary  during  an  enforced  period  of  rest. 

The  underlying  causes  that  sometimes  may  be  found 
provocative  of  angina  pectoris  are  to  be  appropriately  treated, 
such  as  gout,  intestinal  autointoxication,  or  dietary^  indiscre- 
tions. Syphilis  should  be  sought  for  in  the  middle-aged 
stenocardiac  by  the  employment  of  the  Wassermann  sero- 
logic reaction ;  and,  if  a  strong  suspicion  be  not  then  con- 
firmed, the  diagnostic  value  of  the  colloidal-gold  test  should 
not  be  overlooked.  If  lues  be  established,  the  indication  for 
antisyphilitic  treatment  is  plain. 

Between  attacks,  prolonged  courses  of  sodium  iodid  (less 
depressant  than  the  potassium  salt),  in  doses  of  5  to  60  grains 
(0.30  to  4.0  Gm.)  t.  i.  d.  may  be  used  with  benefit.  Atropin 
sulphate  in  /'2.50-  to  Y^q-  grain  (0.0002  to  0.0015  Gm.)  doses  per 
day,  continued  over  long  periods  of  time  has  many  firm  ad- 
herents, who  testify  to  its  efficacy.  In  those  cases  which  are 
accompanied  by  high  systolic  pressure,  the  high-frequency 
current,  referred  to  under  Arteriosclerosis  in  this  chapter,  is 
recommended  b}^  one  no  less  eminent  than  Sir  Clifford  Albutt. 

Digitalis  has  no  place  in  the  treatment  of  angina  pectoris. 
Even  when  it  would  seem  to  be  indicated  by  intercurrent  car- 
diac conditions,  its  employment  should  be  a  matter  of  much 
debate.  During  a  parox3-sm,  pearls  of  amyl  nitrate,  each  hold- 
ing 3  minims  (0.15  Gm.)  crushed  and  inhaled,  often  give  a 
prompt  and  gratif^'ing  relief;  they  may  as  often  disappoint, 
but  are  well  worth  exhibition  in  every  patient.  Morphin  in 
^-grain  (0.0165  Gm.)  hypodermic  doses  may  be  required. 
Liquor  trinitrini,  1  per  cent,  solution,  given  in  10-minim 
(0.62  Gm.)  doses,  may  be  efficacious  where  amyl  nitrate  in- 
halations fail ;  this  drug,  however,  requires  a  lapse  of  perhaps 
ten  minutes  before  its  therapeutic  action  becomes  manifest. 
Chloroform  should  not  be  used  to  abate  anginal  paroxysms; 
its  employment  is  perilous  to  the  heart. 


ANEURYSM.  259 

One  further  injunction,  j^crhaps  not  as  superlicial  as  it  would 
at  lirst  seem,  is  to  be  issued  against  meddlesome  interference 
with  the  position  assumed  by  the  patient  during-  a  paroxysm. 
The  sufferer  assumes  that  attitude  and  position  whicli  at  the 
moment  causes  him  the  least  anguish ;  to  permit  an  over- 
solicitous  relative  or  friend  to  force  him  into  a  position  that 
adds  to  his  distress  is  mistaken  kindness,  and  may  do  actual 
harm. 

ANEURYSM. 

An  aneurysm  is  a  circumscribed  dilatation  of  a  blood- 
vessel. The  saccular  variety  is  recognized  clinically  far 
more  often  than  is  the  fusiform  type,  being  more  prone  to 
reveal  its  presence  in  the  thorax  by  causing  erosions  of  the 
chest-wall ;  when  arising  in  the  abdominal  aorta  (a  circum- 
stance of  10  per  cent,  less  frequent  occurrence),  it  presents 
certain  physical  signs  which  render  its  detection  through  the 
less  rigid  abdominal  wall  a  much  less  complex  question  of 
diagnosis.  Recognizing  that  aneurysms  may,  of  course,  arise 
in  any  blood-vessel,  and  that  they  may  be  of  many  shapes,  and 
of  infinite  variety,  we  shall  concern  ourselves  with  the  symp- 
toms and  treatment  of  only  the  more  frequent  thoracic  and 
abdominal-aortic  types. 

A  primary  inflammation  and  consequent  weakening  of  the 
vessel-wall,  usually  at  a  point  where  the  whirling  blood- 
stream from  the  heart  impinges  upon  the  vessel,  and  thus  fur- 
ther threatens,  by  erosion,  the  integrity  of  the  tube,  satis- 
factorily explains  the  frequency  of  aneurysm  of  the  ascending 
and  transverse  arch  or  the  thoracic  aorta.  Heretofore  it  has 
been  customary  to  ascribe  the  initial  inflammation  to  toxic 
substances,  syphilis,  rheumatism,  alcohol,  injuries,  and  even  to 
the  traumatism  produced  by*^ elongated  and  roughened  aortic 
cusps  striking  the  intima  of  the  aorta,  but  it  appears  from 
recent  investigations  that  S3'philis  is  the  cause  of  aneurysm 
in  all  but  a  negligible  number  of  cases.  The  patient  and 
laborious  researches  of  Warthin,  of  Ann  Arbor,i"  who,  after 
months  of  exhaustive  examination,  was  able  to  demonstrate 
the  Spirocheta  pallida  in  the  aorta  of  practically  80  per  cent,  of 
the  successive,  unselected,  and  routine  autopsies  Avhich  he 
performed,  would  seem  to  indicate  that  the  spirochete  exhibits 


260      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

a  marked  predilection  for  the  aorta.  With  syphilis  thus  so 
strikingly  demonstrated  as  furnishing  the  initial  damage  to 
the  aorta,  it  requires  but  little  imagination  to  conceive  of  the 
blood-pressure  being  sufificiently  raised  by  subsequent  infec- 
tions, alcoholism  or  toxins,  to  cause  erosion  of  the  vessel  to 
the  point  of  aneurysmal  formation. 


Right  clavicle  ^^ '       — 

First  rib 


Aneurismal  sac 


Ascending  aortic  arch 
Pulmonary  artery 


Conus  arteriosus 


Innominate  artery 


i  Lei  t  common  carotid 

artery 


Left  subclavian  artery 


^  Descending  aortic  arch 


Right  ventricle 


.  Fig.  16. — Saccular  aneurj^sm  of  the  aortic  arch  (Philadelphia 
General  Hospital).  (From  Da  Costa's  Ph3fsical  Diagnosis.  Copy- 
right, W.  B.  Saunders  Co.) 


Aneurysm  is  usually  met  with  during  early  middle  life. 
It  is  six  times  more  common  in  men  than  in  women.  Occupa- 
tion does  not  predispose  to  its  occurrence,  although  violent 
exertion  or  long-continued  strain  may  precipitate  urgent 
symptoms  in  a  hitherto  unsuspected  case. 


ANEURYSM. 


261 


It  should  be  borne  in  mind  that  the  symptomatology  of 
aneurysm  depends  upon  the  size  of  the  tumor,  and  upon  its 
location.  It  may  be  so  small  and  so  deep-seated  as  to  escape 
detection,  and  may  so  dispose  itself  as  not  to  cause  suggestive 
pressure  symptoms,  so  that  its  existence  is  undiscovered  in 
routine  physical  examinations. 

Thoracic  Aneurysm.  Pain  is  sharp  and  acute  if  a  nerve  be 
pressed  upon,  boring  in  character  if  a  bone  is  implicated ;  parox- 


X. 


_± 


Fig.  17. — Aneurysm  of  the  ascending  aortic  arch  (Jefferson 
Hospital).  (From  Da  Costa's  Physical  Diagnosis.  Copyright,  W. 
B.  Saunders  Co.) 

ysmal  attacks  may  simulate  angina  pectoris.  Dyspnea  on 
exertion  may  be  manifest;  brassy  coug'h,  with  alteration  of 
the  voice,  due  to  pressure  upon  the  recurrent  laryngeal  nerve ; 
contracted  or  dilated  pupils  if  the  sympathetic  nerves  be 
pressed  upon,  together  w^ith  unilateral  perspiration,  are  symp- 
toms frequently  presented.  When  inspecting  the  surface  of 
the  chest,  the  patient  should  be  prone,  and  the  eyes  of  the  ex- 
aminer should  be  on  a  level  with  the  sternum;  under  these 
circumstances  an  abnormally  situated  pulsation,  laterally  ex- 
pansile in  character,  and  giving  rise  to  a  systolic  or  diastolic 


262       DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

thrill,  may  be  detected.  The  back  should  be  carefully  exam- 
ined to  discover  an  aneurysm  which  may  point  in  that  direc- 
tion. A  delayed  or  feeble  pulse  is  frequently  found  when  one 
radial  is  compared  with  the  other;  variations  in  the  carotids 
also  ma}^  be  present ;  both  these  phenomena  are  of  significance 
in  locating  the  position  of  the  aneurysm.  Downward  tracheal 
tugging,  first  described  by  Oliver,  is  a  valuable,  though  not 
pathognomonic,  sign  of  aneurysm.  It  is  caused  by  pulsations 
in  the  arch  as  it  passes  over  the  primary  left  bronchus,  and  is 
elicited  by  having  the  patient  throw  his  head  back,  thus 
stretching  the  trachea.  The  physician,  who  is  standing  behind 
the  patient,  now  gently  places  his  thumb  and  forefinger  under 
the  lower  border  of  the  cricoid  cartilage,  and  the  tracheal  tug  is 
elicited.  It  is  not  to  be  confused  with  inspiratory  movements, 
nor  with  pulsations  in  the  neck. 

Hypertrophy  and  dilatation  of  the  heart,  long  considered 
classic  signs  of  aneurysm,  are  found  in  less  than  1  per  cent, 
of  cases,  according  to  Howard's  autopsy  statistics.!^  The 
heart  may,  of  course,  be  pressed  downward  and  to  the  left  to 
accommodate  the  new  growth  within  the  chest.  An  increase 
in  the  area  of  aortic  dullness  is  the  most  constant  physical 
sign  in  early  thoracic  aneurysm.  Rarely  the  lungs  are 
pressed  upon,  giving  us  pulmonary  physical  signs ;  or  a  bron- 
chus may  be  occluded,  and  cause  an  atelectatic  lung. 

Abdominal  Aneurysm.  Aneurysm  occurring  in  the  abdom- 
inal aorta,  if  of  appreciable  size  presents  the  symptoms  of  a 
pulsating  tumor,  usually  to  the  left  of  the  vertebral  column, 
and  above  the  umbilicus.  A  systolic  thrill  and  systolic  mur- 
mur, and  even  at  times  a  diastolic  murmur,  may  be  heard, 
associated  with  pressure  symptoms.  Should  the  aneurysm 
point  backward,  compressing  the  solar  plexus,  pain  of  a  lan- 
cinating character  may  be  expected ;  if  pressure  be  exerted  on 
the  lumbar  nerves,  pain  will  be  referred  to  the  region  supplied 
by  the  nerv^e,  usuall}-  in  the  left  groin  and  affecting  the  left 
leg.  Gastrointestinal  symptoms  arise  if  the  growth  is  directed 
anteriorly.  Erosion  of  the  spine  may  occur  in  abdominal 
aneurysm.  Although  rare,  such  an  incident  was  observed  in 
the  wards  of  the  Pennsylvania  Hospital:  a  patient  admitted 
for  abdominal  pain  suddenly  died;  in  lifting  the  body  to  the 
autopsy  table  the  spine  broke  in  twain,  and  a  large,  sacculated 


ANEURYSM.  263 

aneurysm  was  found  to  have  eroded  tlie  si)ine  to  the  breaking- 
point.  Abdominal  aneurysm  may  be  differentiated  from 
other  growths  in  that  location  by  the  expansile,  pulsating 
nature  of  the  tumor,  and  by  a  maneuver  sug-gested  by  Osier, 
who  noted  that  when  the  patient  is  put  in  the  knee-chest  posi- 
tion, other  abdominal  tumors  chang'e  their  location,  but  an 
aneurysm  remains  constant  in  its  position  and  characteristics. 

The  .r-ray  plate,  or  preferably  fluoroscopy,  is  our  most 
dependable  means  of  early  diag"nosis,  confirming-  the  opinions 
established  by  physical  sig'ns  and  detecting  pulsating  tumors 
in  cases  where  a  reasonable  doubt  exists. 

The  prognosis  is  distinctly  unfavorable,  although  patients 
who  are  well  cared  for  and  carefully  watched  may  lead  a  life 
of  invalidism  for  years.  Relatives  should  be  acquainted  with 
the  probability  of  sudden  rupture  of  the  sac,  and  of  its  fatal 
consequences.  Recent  statistics  indicate  that  the  average 
length  of  life  is  two  years  after  an  aneurysm  has  been 
diagnosed. 

TREATMENT. 

Manifestly,  no  treatment  will  restore  the  lost  integrity  of 
the  vessel-wall.  To  the  amelioration  of  symptoms  and  to  the 
prolongation  of  life  we  must  direct  our  attention.  If  the 
Wassermann  serologic  reaction  be  positive,  salvarsan  or  neo- 
salvarsan  is  indicated,  in  the  hope  of  minimizing  the  active 
inflammation  of  the  aorta.  The  careful  physician  will  not  be 
content  with  a  negative  Wassermann,  but  will,  in  such  a  cir- 
cumstance, employ  the  colloidal-gold  test  in  an  examination 
of  the  spinal  fluid. 

Salvarsan,  or  ''606,"  is  an  arsenical  preparation  introduced 
by  Ehrlich,  and  is  a  yellow,'  crystalline  powder,  containing 
about  one-third  by  weight"  of  arsenic.  The  average  dose  for 
an  adult  is  about  0.5  Gm.  {7 .7  grains)  for  each  60  kilos  (132 
lbs.)  of  body  weight.  It  may  be  found  advisable  to  administer 
a  smaller  initial  dose  to  observe  the  reaction  thereto.  Many 
of  the  violent  reactions  have  been  found  to  be  due  to  the  use 
of  improperly  prepared  solutions.  The  ampoule  containing  the 
powder  is  cleansed  with  alcohol,  and  the  neck  filed  and  broken. 
The  powder  is  dissolved  in  a  small  beaker  containing  50  mils 
(1^  oz.)  of  absolutely  fresh  distilled  water;  the  solution  may 


264       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

be  gently  stirred  or  shaken  to  favor  solution  of  the  drug. 
The  clear,  yellow,  acid  solution  is  then  neutralized  by  the  addi- 
tion, drop  by  drop,  of  a  fresh  15  per  cent,  solution  of  sodium 
hydroxid.  The  resulting  precipitate  becomes  dissolved  as  the 
reaction  of  the  solution  becomes  slightly  alkaline.  The  solu- 
tion is  then  diluted  with  from  100  to  200  mils  {3.3  to  7  oz.)  of 
saline  solution,  freshly  prepared,  and  is  then  filtered  through 
sterile  cotton.  A  special  needle  may  be  used  to  insert  into  the 
vein  through  the  skin,  or  the  vein  may  be  exposed  as  in  vene- 
section. The  median  basilic  vein  is  the  location  of  choice  for 
the  injection.  The  patient  should  receive  the  drug  in  the  re- 
cumbent position,  and  should  stay  quietly  in  bed  for  several 
hours  afterw^ard. 

Neosalvarsan  is  administered  in  the  same  manner.  No 
neutralization  is  necessary  with  it.  Both  these  drugs  may  be 
given  intravenously  by  syringe,  the  drug  being  dissolved  in 
30  mils  (1  oz.)  of  water.  In  this  manner  the  vomiting,  nausea, 
and  chills(  caused  by  larger  quantities  of  the  solution  may  be 
avoided.  The  reactions  are  due,  as  a  rule,  to  the  use  of 
"old"  or  not  properly  distilled  water.  The  drug  dissolved 
in  oil  may  be  administered  by  intramuscular  injections, 
but  these  are,  as  a  rule,  so  painful  that  this  method  is  not 
much  used. 

The  repetition  of  the  dose  will  depend  upon  clinical  find- 
ings, and  upon  the  condition  of  the  blood  as  revealed  by  the 
Wassermann  reaction.  As  a  rule,  the  late  secondary  or  early 
tertiary  conditions,  as  manifested  in  earl)^  cardiovascular  con- 
ditions, W'ill  be  found  to  present  a  positive  AA'assermann  test 
over  a  long  period  of  time  under  salvarsan  therapy  alone,  and 
it  must  be  supplemented  by  the  judicious  administration  of 
mercury  and  the  iodids.  (For  further  details  of  the  technic  of 
administering  these  arsenical  preparations  the  reader  is  re- 
ferred to  Syphilis,  vol.  i,  p.  80.) 

Rest  is  a  prime  requisite  in  reducing  arterial  pressure,  as 
detailed  under  Arteriosclerosis  {q.  v.).  The  patient  will  as- 
sume that  posture  Avhich  is  the  most  comfortable  for  him, 
and  rarely  is  it  necessary  for  the  physician  to  interfere  in  the 
matter  of  posture.  It  is  customar)'-  for  certain  physicians  to 
use  veratinim  viride  in  the  routine  treatment  of  aneurysm,  but 
we  cannot  subscribe  to  its  employment. 


Aneurysm.  265 

Venesection,  with  the  withdrawal  of  20  to  30  ounces  (591 
to  887  mils)  of  blood,  may  be  of  value  in  relieving  pain,  and 
the  efifect  at  times  is  surprisingly  long-continued.  The  effect 
of  an  ice-bag  applied  to  the  precordium  is  often  gratifying  in 
quieting-  an  overactive  heart  and  in  lessening  pain.  It  may 
remain  in  place  fifteen  or  twenty  minutes,  the  interval  of 
application  being  lengthened  according  to  the  comfort  of  the 
patient. 

The  pain  of  aneurysm  is  to  be  relieved  by  the  employment 
of  the  less  depressant  analgesics  of  the,  coal-tar  derivatives, 
such  as  phenacetin  or  aspirin,  in  doses  of  from  5  to  10  grains 
(0.33  to  0.66  Gm.)  at  three-hour  intervals  until  effective;  if 
no  response  is  secured,  morphin,  in  the  dose  of  3^  to  ^  grain 
(0.0082  to  0.0165  Gm.)  is  administered  hypodermically.  The 
possible  induction  of  the  opium  habit,  as  well  as  a  pernicious 
alteration  of  the  bodily  secretions,  in  a  diseased  condition 
which  may  extend  over  a  period  of  years,  is  to  be  borne  in 
mind  by  the  attending  physician.  The  distressing  cough  so 
common  in  aneurysm  as  a  result  of  pressure  symptoms  is  diffi- 
cult of  control.  Dionin,  given  in  a  simple  elixir  in  J^-  to  ^- 
grain  (0.0082  to  0.0165  Gm.)  doses  at  four-hour  intervals,  may 
be  tried.  Counterirritation  applied  to  the  pectoral  region  is 
also  of  some  service. 

lodid  of  potassium,  in  5-  to  10-  grain  (0.33  to  0.66  Gm.) 
doses  t.  i.  d.,  is  widely  employed  in  the  treatment  of  aneurysm. 

Tufnell  suggested  a  treatment  for  aneurysm,  to  which  Bal- 
four added  the  routine  administration  of  potassium  iodid, 
which  consists  of  mental  and  physical  rest,  with  moderate  diet, 
the  patient  being  confined  to  bed  for  a  period  of  from  six  weeks 
to  three  months.  The  rationale  of  the  method  is  to  diminish 
blood-pressure  and  to  increase  the  proportion  to  fibrin  in  the 
blood,  thus  promoting  coagulation.  For  breakfast  and  supper 
Tufnell  allows  2  ounces  (60  Gms.)  of  bread  and  butter,  2 
ounces  (60  mils)  of  milk ;  for  dinner,  2  or  3  ounces  (60  or  90 
Gms.)  of  meat,  and  3  or  4  ounces  (90  or  120  mils)  of  milk  or 
claret  are  permitted.  While  to  many  patients  this  treatment 
v/ould  seem  more  of  an  imposition  than  a  therapeutic  measure, 
beneficial  results  have  been  reported  from  its  use. 

When  circulatory  failure  ensues  in  aneurysm,  and  the  heart 
requires  support,  digitalis  is  exhibited  in  moderate  dosage,  5  to 


266      DISEASES    OF    THE    CARDIOVASCULAR   SYSTEM. 

10  drops  (0.31  to  0.62  mil)  of  the  tincture  being  given  at  fouf- 
hour  intervals  until  improvement  results.  As  stated  under 
Arteriosclerosis,  the  effects  of  digitalis  are  to  be  carefully- 
watched  for  the  occurrence  of  coupled  beats  or  other  evi- 
dences of  untoward  eft'ect. 

The  JJ^iriiig  of  an  Aneurysm.  A  sacculated  thoracic  aneu- 
rysm may  be  treated  by^  the  introduction  of  a  fine  platinum- 
gold  wire  into  the  sac.  It  is  an  operation  not  to  be  undertaken 
lightly,  nor  by  those  Avho  liaA'e  had  no  experience  with  the 
technic  employed.  The  introduction  of  the  cannula  through 
which  the  wire  is  passed  may  result  in  sudden  rupture  of  the 
aneur}'sm — a  possibility  that  should  be  explained  to  the  pa- 
tient and  his  relatives  beforehand.  The  operation  has  been  at- 
tended with  brilliant  results  in  many  instances.  One  patient 
whom  we  have  in  mind,  where  the  aneurysm  protruded  from 
the  thoracic  wall,  and  presented  a  gangrenous  area  which 
threatened  early  rupture,  was  given  a  prospective  life  tenure  of 
six  months  by  a  competent  surgical  consultant.  The  operation 
of  wiring  was  performed,  and  the  patient  led  a  moderately 
active  life,  in  which  none  of  his  pleasures  were  curtailed,  for 
nine  years.  At  autopsy  the  wiring  was  found  to  have  formed 
a  matress  of  fibrin  between  the  currents  of  blood  and  the 
chest-wall.  AMring  should  not  be  performed  as  a  last  resort; 
when  it  is  done  moderately  early  in  the  condition,  it  oft'ers 
more  hope  of  a  gratifying  result.  The  possibility  that  the 
wiring  of  an  aneurysm  at  one  point  may  so  deflect  the  blood- 
stream as  to  cause  a  sacculation  to  appear  at  another  and  in- 
accessible point  in  the  A-essel-wall.  should  not  stay  our  hand 
if  the  procedure  is  indicated  and  the  case  a  suitable  one. 

In  the  Corradi  method,  after  sterilization  of  the  skin  over 
the  aneurysm,  fine  platinum-gold  wire  is  introduced  through 
a  small  porcelain-  or  lacquer-  covered  cannula  into  the  sac. 
From  ten  to  fifteen  feet  (300  to  450  cm.)  of  wire  are  intro- 
duced, depending  upon  the  size  of  the  sac,  and  as  much  as 
forty-five  feet  (1350  cm.)  have  been  required  in  some  instances. 
The  end  of  the  platinum-gold  wire  is  now  connected  to  the 
positive-pole  electrode  of  a  galvanic  batter}^,  and  the  current 
completed  by  placing  a  large  wet  electrode,  connected  with 
the  negative  pole,  upon  the  patient's  back.  The  current  is 
turned  on  to  5  milliamperes,  and  increased  that  much  every 


ARTERIOSCLEROSIS.  267 

five  minutes,  until  50  milliampcres  are  being  used.  The  acid 
reaction  produced  by  electrolysis  about  the  g'old  wire  produces 
a  firm  clot,  and  by  the  end  of  half  an  hour  pulsation  in  the 
sac  will  be  found  to  be  notably  diminished.  No  other  alloy 
than  platinum  should  be  employed ;  a  copper  alloy  will  be  dis- 
solved under  the  electric,  current.  If  an  excess  of  platinum  be 
in  the  wire,  it  may  be  so  "springy"  as  to  push  aside  any  fibrin 
already  deposited  on  the  vessel-wall,  and,  by  its  resistance, 
actually  push  out  the  walls  of  the  sac  and  thus  defeat  the 
purposes  of  the  operation.  At  the  end  of  from  thirty  minutes 
to  an  hour,  the  electrodes  are  disconnected,  and  the  free  end 
of  the  wire  pushed  beneath  the  skin,  the  cannula  withdrawn, 
and  the  puncture  sealed.  This  procedure  has  been  successful 
in  closing"  the  sac  in  several  instances,  one  of  the  most  bene- 
ficial results  having  been  the  marked  relief  from  pain,  which 
often  occurs  within  five  minutes  following  the  operation. 
After  wiring  an  aneurysm,  the  patient  should  remain  perfectly 
quiet  in  bed  for  a  period,  of  two  or  three  weeks,  to  favor  con- 
solidation of  the  clot. 

ARTERIOSCLEROSIS. 

Arteriosclerosis  is  a  term  used  to  describe  a  progressive 
degenerative  change  in  the  intima  of  blood-vessels,  resulting  in 
an  inflammatory  or  a  calcareous  thickening  of  the  vessel  walls. 
The  symptomatology  is  variable,  depending  upon  the  nutritive 
changes  induced  in  the  organ  or  organs  whose  arterial  supply 
is  thus  diminished. 

It  is  convenient  to  group  the  causes  of  arteriosclerosis 
under  three  heads,  viz:  (1)  those  with  an  antecedent 
history  of  infectious  processes,  usually  long  continued ;  (2) 
those  due  to  toxic  conditions;  (3)  and,  finally,  those  physical 
changes  incident  to  the  advance  of  years,  especially  in  the  tem- 
peramentally, high-strung,  emotional  victims  of  modern  high- 
pressure  living.  All  three  conditions  have  a  similar  eflfect  upon 
the  musculature  of  the  arteries  in  producing  an  increased  blood- 
pressure,  which  eventually  damages  the  vessel  wall,  and  in 
this  thickened  musculature  the  subsequent  degenerative 
change  occurs. 

Among  the  infections  we  recognize  as  etiologic  factors 
rheumatic  fever,  syphilis,  tuberculosis,  typhoid  fever,  and  long 


268      DISEASES   OF   THE   CARDIOVASCULAR   SYSTEM. 

continued  absorption  from  suppurative  foci,  to  which  the  un- 
fortunate term  "rheumatism"  has  hitherto  been  appHed,  but 
to  which  we  now  refer  under  the  suggestive  terminology 
"Streptococcosis." 

Toxic  factors  embrace  the  poisons  of  alcoholism,  gout, 
plumbism,  uremia,  and  the  altered  chemistr}^  of  the  body  at- 
tendant upon  diabetes. 

The  capillaries  are  usually  the  seat  of  a  sclerotic  change, 
which  occludes  their  lum.en  and  thus  destroys  the  circulatory 
balance  between  the  arterial  and  venous  systems.  The  arte- 
rioles and  the  arteries  become  progressively  thickened,  and 
impose  excess  labor  upon  the  heart.  The  lesions  of  arterial 
thickening,  calcareous  deposits,  and  calcification  of  the  vessels 
are  not  always  universally  and  equally  distributed.  Changes 
may  be  found  only  in  the  vessels  supplying  the  brain,  or  per- 
haps implicate  solely  those  of  the  kidneys,  liver,  or  digestive 
organs. 

The  frequent  association  of  arteriosclerosis  and  glomerulo- 
nephritis has  given  rise  to  much  academic  discussion  as 
to  which  of  the  lesions  is  cause  and  which  is  effect.  It 
may  be  logically  assumed  that  any  congestion  or  inflammation 
of  the  kidne}'  which  interferes  with  its  circulation  will  require 
an  increased  effort  on  the  part  of  the  blood-vessels  supplying 
the  organ,  this  overaction  eventually  resulting  in  a  degenera- 
tive change  in  the  vessels. 

Owang  to  the  cardiac  effort  necessary  to  maintain  the  cir- 
culation, sclerotic  areas  in  the  musculature  of  the  heart  and 
h3^pertrophy  of  the  left  ventricle  are  commonly  observed  at 
autopsy.  These  changes  give  rise  during  life  to  pulse  irregu- 
larities and  cardiac  symptoms,  which  often  furnish  the  first 
clue  to  the  detection  of  arteriosclerosis. 

Universally  regarded  as  a  condition  occurring  in  the  later 
period  of  life,  arteriosclerosis  is  not  confined  to  the  aged,  and  it 
may  be  recognized  in  middle  life.  It  is  of  frequent  occurrence 
among  males,  owing  to  the  more  vigorous,  rigorous,  and 
exposed  mode  of  life  in  the  man. 

The  symptoms  vary  with  the  organ  or  organs  predomi- 
nantly affected.  If  the  vessels  of  the  brain  are  sclerosed,  men- 
tal fatigue,  drowsiness,  loss  of  memory,  confusion,  and  syn- 
copal attacks  may  provoke  the  rupture  of  a  vessel  with  its 


ARTERIOSCLEROSIS. 


269 


consequent  symptoms  of  apoplexy.  Should  the  abdominal 
viscera  be  partly  robbed  of  their  nourishment  through  arterial 
degeneration,  gastrointestinal  symptoms  dominate  the  picture. 
When  the  vessels  of  an  extremity  are  sclerotic,  attention 
is  attracted  by  thermal  and  sensory  changes  in  the  part 
affected,  often  with  limitations  of  normal  muscular  move- 
ment and  early  muscular  exhaustion  produced  by  moderate 
effort.  If  the  kidneys  are  the  organs  dominantly  affected,  the 
usual  clinical  evidences  of  lack  of  elimination,  absorption  of 
toxins,  and  genito-urinary  syndromes  are  obvious.  It  should 
be  borne  in  mind  that  in  any  of  the  conditions  mentioned,  evi- 
dences of  beginning  cardiac  disturbance  are  quite  constantly 
present  in  the  symptom-complex.  Sclerosis  of  the  radials, 
temporals,  or  other  palpable  arteries  may  or  may  not  be  pres- 


Fig.  18. — Arteriosclerosis. 

F.,  aged  80.  Normal  rhythm;  rate  80;  a-c  interval  0.2  second;  loss  of  arterial 
elasticity  shown  by  blending  of  percussion  and  tidal  waves,  sustained  summit 
and  oblique  decline  of  pulse  wave.  The  aortic  notch  is  clearly  shown,  but  the 
following  dicrotic  wave  is  poorly  marked.     (Courtesy  of  Dr.  Ross  T.  Patterson.) 

ent;  the  skin  may  or  may  not  be  dry,  cool,  relaxed,  and 
wrinkled.  We  are  concerned  now  with  the  early  recognition 
of  arteriosclerotic  change  in  those  under  our  care,  and  two 
symptoms  in  particular  should  excite  the  suspicion  of  begin- 
ning arteriosclerosis :  the  first  is  high  arterial  tension,  and  the 
second  is  the  evidence  presented  by  a  heart  working  under 
load. 

The  earliest  symptom  of  beginning  arteriosclerosis  may  be 
a  curtailment  of  the  normal  amount  of  effort  of  which  the 
heart  has  hitherto  been  unconscious.  In  a  patient,  usually 
past  the  meridian  of  life,  who  complains  of  breathlessness  on 
moderate  exertion,  dizziness,  confusion,  precordial  pain  or 
distress,  palpitation,  cold  extremities,  insomnia,  anginal  symp- 
toms, bronchitis,  puffiness  of  the  extremities,  and  dropsy,  we 


270      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

should  at  once  suspect  arterial  degeneration.  If  the  systoli; 
pressure  be  constantly  from  30  to  60  mm.  (0.9  to  1.19  in.) 
higher  than  the  average  pressure  for  a  given  age,  and  is  other- 
wise unaccounted  for,  arteriosclerosis  is  probable.  The  aver- 
age systolic  pressure  may  be  conveniently  estimated  at  100 
plus  the  age,  allowing  normal  variations  therefrom  of  17 
degrees  in  either  direction,  the  estimate  for  women  being  10 
mm.  lower — 0.3937  in.  If,  added  to  this,  a  sharp,  accentuated 
first  sound  at  the  apex  and  an  intensified  second  sound  at  the 
base  are  audible,  showing  increased  effort  of  the  myocardium, 
our  suspicions  become  still  more  tenable ;  and  if,  in  palpating 
the  radial,  brachial,  or  temporal  arteries,  we  find  an  increased 
sense  of  resistance  in  a  vessel  that  remains  full  between  beats, 
we  may  consider  that  the  diagnosis  of  arteriosclerosis  may  be 
provisionally  made. 

Attention  is  frequently  drawn  to  the  heart  by  a  change  of 
its  rhythm,  due  to  a  premature  contraction  or  dropped  beat. 
If  the  premature  systole  is  unaccompanied  by  other  signs 
of  cardiac  disturbance,  it  may  be  disregarded;  a  dropped 
beat,  however,  should  keep  us  on  the  qui  vive  for  heart- 
block.  The  sphygmograph  or  electrocardiograph  may  be  of 
great  value  in  determining  and  dififerentiating  these  condi- 
tions, as  well  as  in  keeping  us  informed  of  the  progress  of  the 
affection. 

Interest  has  recently  been  revived  in  the  comparative  in- 
tensity of  the  first  and  second  heart-sounds  as  a  method  of  de- 
termining the  functional  capacity  of  the  all-essential  heart- 
muscle.  It  consists  of  auscultating  first  over  the  cardiac  im- 
pulse at  the  apex  with  a  stethoscope  designed  gradually  to 
reduce  the  sound  to  the  point  of  disappearance,  which  point 
is  expressed  in  figures  on  a  measured  scale  of  the  instrument. 
The  second  sound  is  now  auscultated  at  the  aortic  area  in  a 
similar  manner ;  the  ratio  should  be  2 :  1  in  normal  hearts.  If, 
however,  the  first  sound  be  of  equal  intensity  with  the  second, 
or  if  it  be  less  than  the  second,  the  indications  for  absolute 
rest  in  bed,  to  relieve  the  affected  myocardium,  are  imperative. 
Electrocardiography  has  many--stanch  supporters,  who  believe 
it  will  prove  to  be  the '  court  of  last  resort  in  estimating 
the  efficiency  of  the  cardiac  muscle  and  the  extent  of  damage 
thereto. 


ARTERJOSCLEROSIS.  271 

The  later  and  classical  symptoms  of  arteriosclerosis  are 
varying  degrees  of  arterial  hardening,  which  include  indura- 
tion, calcareous  deposits  ("beading,"  detected  by  running  the 
finger  along  the  artery),  the  tortuous  and  infiltrated  radial, 
the  "pipe-stem"  artery,  and  the  "snappy"  brachial.  Added  to 
these  are  left  ventricular  hypertrophy,  increase  of  the  trans- 
verse area  of  cardiac  dullness  (normally  9]^  to  11  cm.  [3)4  to 
Ayl  in.]),  frequently  a  fall  of  arterial  pressure,  systolic  aortic 
murmurs,  angina  pectoris,  an  ungoverned  heart,  gangrenous 
areas  due  to  obliterative  endarteritis,  pulmonary  edema, 
venous  stasis,  and  chronic  invalidism.  Such  late  cases  may 
present  either  auricular  fibrillation  or  heart-block  {q.  v.),  de- 
pending upon  which  part  of  the  heart  is  damaged,  and  toward 
the  end  of  life  may  develop  a  pulsus  alternans. 

Arteriosclerosis  is  essentially  progressive  in  nature.  With 
its  early  recognition  and  the  institution  of  a  proper  mode  of  life, 
we  may  hope  to  avoid  sudden  deaths  in  unrecognized  cases,  and 
may  express  a  guarded  but  hopeful  prognosis  to  those  who  pre- 
sent no  serious  lesion  of  the  all-essential  heart-muscle.  Indeed, 
an  additional  tenure  of  from  ten  to  twenty  years  has  been  ob- 
tained by  those  who  were  thoughtful  in  carrying  out  instruc- 
tions, and  provident  in  the  expenditure  of  their  energ}^  Far 
advanced  cases  are,  of  course,  regarded  as  critical. 

TREATMENT. 

Arterial  thickening,  degeneration,  or  calcification,  when 
once  established,  is  amenable  to  no  treatment.  Much  value, 
however,  can  be  obtained  from  a*  proper  hygienic  and  dietetic 
reg"imen.  A  rational  method  of  living,  the  avoidance  of  phy- 
sical strain  and  emotional  stress,  with  strict  attention  to  an 
easily-assimilable  diet,  and  to  the  alimentary  canal  will  keep 
the  patient  comfortable,  and  perhaps  unaware  of  the  progress 
of  the  condition. 

High  blood-pressure  in  arteriosclerosis  may  be  safely  re- 
garded as  an  expression  on  the  part  of  nature  to  maintain  the 
circulatory  balance  necessary  for  the  nourishment  of  the  body. 
If  this  view  be  tenable,  it  appears  obvious  that  the  employ- 
ment of  arterial  sedatives,  such  as  veratrum  viride,  may  well 
be  referred  to  as  meddlesome  therapeutics.  The  daily  demand 
upon  the  heart  is  diminished  by  putting  the  patient  at  rest  in 


272      DISEASES    OF    THE    CARDIOA'ASCULAR    SYSTEM. 

bed,  interdicting  emotional  disturbances,  securing  elimination, 
and  prohibiting  the  intake  of  meats  and  animal  broths,  thus  re- 
ducing the  protein  constituents  of  food.  When  such  a  routine 
is  instituted,  the  blood-pressure  often  shows  a  gratifying  re- 
duction, and  relieves  one  of  the  responsibility  of  interfering 
by  drugs  with  a  phenomenon  not  as  yet  thoroughly  understood. 

In  arteriosclerosis,  as  in  all  disease  conditions,  rest  and 
elimination  relieve  the  burden  of  wearied  nature,  and  strengthen 
the  patient.  Rest  is  secured  by  abjuring  all  business  cares  and 
worries  and  by  the  avoidance  of  ph3-sical  exertion ;  a  few  weeks 
in  bed  at  home  or  at  a  sanatorium,  an  ocean  voyage,  or  change 
of  climate,  with  its  enforced  rest  and  varied  mental  occupation, 
may  be  indicated.  Following  the  initial  recuperative  period, 
judicious  exercise  should  be  prescribed. 

The  milder  saline  laxatives  secure  elimination  by  the 
bowels;  the  simpler  diuretics  aid  elimination  by  the  kid- 
neys; tepid  baths  assist  in  elimination  by  the  skin.  Sudden 
temperature  changes  or  either  extreme  in  hot  or  cold  baths  are 
often  dangerous  to  arteriosclerotics. 

If  a  positive  AA'assermann  reaction  demonstrates  the  pres- 
ence of  the  living  Spirocheta  pallida  in  the  body,  salvarsan  or 
neosalvarsan  are  to  be  resorted  to  until  negative  reactions  are 
secured  {vs.). 

Among  drugs,  the  alterative  iodid  of  potassium  has  long 
held  first  place  in  the  treatment  of  this  condition,  its  reputa- 
tion being  based  on  its  power  to  relieve  the  minor  symptoms 
of  dizziness,  headache,  breathlessness,  and  exhaustion.  It  is 
given  in  doses  of  5  to  10  grains  (0.33  to  0.66  Gm.),  well  diluted, 
after  meals ;  occasionally  it  is  rapidly  pushed  to  the  point  of 
physiologic  tolerance,  and  there  maintained  at  moderate  dos- 
age. Nux  vomica  (dose  of  tincture.  10  to  30  gtt.  (0.62  to  1.85 
mils)  t.  i.  d.,  p.  c.)  or  its  alkaloids  ma}^  be  required  for  a  tonic 
effect  upon  the  gastro-intestinal  tract  or  upon  the  system  in 
general. 

Insomnia  is  combated  by  those  hypnotics  which  often  seem 
peculiarly  eftective  in  heart  conditions,  viz.,  veronal,  tetronal, 
trional,  sulphonal,  or  medinal,  given  before  retiring,  in  5-  to 
10-  grain  (0.33  to  0.66  Gm.')  doses  dissolved  in  half  a  cup  of  hot 
water.  It  ma}^  be  necessar}^  to  substitute  one  preparation  for 
another,  inasmuch  as  the  efficiency  of  hypnotics  tends  to  de- 


BLOOD-PRESSURE.  273 

crease  with  their  accustomed  use.  Rarely,  chloral  hydrate,  in 
doses  of  5  to  10  t^rains  (0.33  to  0.66  Gm.)  is  indicated,  but  this 
drug  is  to  be  cautiously  employed.  The  bromids,  in  15-  to 
20-  grain  (0.99  to  1.22  Gm.)  doses,  are  effective  nerve  seda- 
tives. Opium  or  its  derivatives  are  rarely  used  in  the  pres- 
ence of  pulmonary  congestion  of  any  degree,  for  fear  of 
adding  the  additional  weight  of  retained  secretions  to  the 
already  burdened  heart. 

The  sovereign  heart-remedy,  digitalis,  one  of  the  most 
effective  and  most  abused  drugs  in  the  pharmacopeia,  is  em- 
ployed only  when  circulatory  failure  ensues,  or  when  degenera- 
tive changes  in  the  heart-muscle  makes  its  use  imperative,  but, 
even  in  the  presence  of  these  classical  indications,  we  must 
determine  that  heart-block  is  neither  impending  nor  present, 
for  in  heart-block  digitalis  frequently  induces  alarming  symp- 
toms, and  perhaps  fatal  results. 

On  the  other  hand,  in  auricular  iibrillation  arising  in  the 
course  of  arteriosclerosis,  digitalis  has  a  markedly  beneficial 
effect,  through  its  stimulating  action  upon  the  inhibitory  fibers 
of  the  pneumogastric,  which  controls  the  area  of  impulse-for- 
mation, the  sinoauricular  node.  The  dose  of  the  tincture  here 
is  as  much  as  a  dram  {Z.7  mils)  a  day,  reduced  as  symptoms 
of  compensatory  failure  disappear.  When  administering  digi- 
talis or  digalen,  over  a  period  of  days,  the  appearance  of  a 
coupled  pulse,  called  "digitalis  coupling,"  indicates  the  prompt 
withdrawal  of  the  drug.  It  is  to  be  remembered  that  auricular 
fibrillation  may  be  of  sudden  onset,  and  in  a  greatly  damaged 
heart,  attains  an  alarming  degree  that  threatens  life  ;  in  such 
an  actual  emergency  the  intravenous  injection  of  strophanthin 
is  indicated,  the  heroic  dosage  of  %o  of  a-  bfain  (0.00132  Gm.) 
being  appropriate. 

Heart-block  may  also  give  rise  to  an  emergenc}^  in  wdiich 
event  atropin  sulphate  is  used,  hypodermically  or  perhaps  in- 
travenously, in  a  dose  of  %oo  to  ^o  grain  (0.00066  to  0.00132 
Gm.).     {Cf.  p.  216,  et  seq.) 

BLOOD-PRESSURE. 

Following  the  introduction,  within  the  last  decade  of  sev- 
eral mechanical  devices  for  estimating  blood-pressure,  the 
majority   of   the   larger   insurance   cotnpanies   of  the    United 


274      DISEASES    OF   THE    CARDIOVASCLXAR    SYSTEM. 

States  have  required  that  these  clinical  instruments  be  used  by 
their  medical  examiners.  The  result  has  been  a  general  adop- 
tion of  sphygmomanometr}^,  rarely  with  benefit  to  the  appli- 
cant, frequently  to  the  loss  of  otherwise  acceptable  risks  by 
the  insurance  companies,  and  much  to  the  confusion  of  the 
subject  of  sphyg■momanometr}^  The  inrush  of  physicians  into 
a  field  where  they  had  little  opportunity  to  make  the  detailed 
studies  required  by  the  newer  clinical  method  has  caused  the 
publication  of  innumerable  and  hastily  drawn  conclusions ; 
really  competent  obser\"ers  have  spent  much  time  in  disproving- 
and  controverting  unfounded  assertions,  rather  than  devoting 
their  attention  to  establishing  the  promising  future  of  sphyg- 
momanometr}?-  upon  a  scientific  basis.  From  the  haze  of  con- 
tradictory literature  surrounding  the  subject  certain  conclu- 
sions can  be  drawn,  which  are  here  presented  for  the  guidance 
of  the  general  practitioner: 

Instruments.  There  are  two  types  of  instruments — those 
which  express  the  blood-pressure  in  the  readings  obtained 
from  a  column  of  mercury  within  a  graduated  glass  tube,  and 
those  operated  by  a  spring.  The  former  is  considered 
more  accurate ;  the  latter  is  more  convenient  for  general  use, 
more  easily  carried,  and,  if  frequently  compared  with  the 
standard  mercury  scale,  and  corrected  in  conformity  thereto 
is  sufficiently  accurate  for  clinical  estimations.  It  would  seem 
that  the  spring  instrument  is  the  one  of  choice  with  the  major- 
itv  of  the  insurance  companies  who  have  replied  to  circular 
letters  on  the  subject;  it  is  the  one  we  shall  consider  in  this 
discussion.  The  term  "blood-pressure,"  when  it  occurs  in 
literature,  usually  refers  to  the  systolic  estimate. 

The  apparatus  consists  of  a  silk  armlet,  not  less  than  five 
inches  (12.7  cm.)  wide,  which  contains  within  its  folds  a  rub- 
ber "compression-cuff."  To  one  of  the  tubes  supplying  this 
reser\^oir  an  atomizer  bulb,  with  provision  for  the  gradual 
escape  of  the  air  within  the  cuff,  is  applied,  and  to  the  other 
tube  the  dial  or  register  is  attached.  Blood-pressure  is  usually 
estimated  by  binding  the  silk  cuff  about  the  arm,  over  the 
biceps,  in  order  to  compress  the  brachial  arter}-;  or  the  femoral 
arter}^  may  be  used,  but  not  when  the  patient  is  sitting  erect, 
for  in  this  instance  it  registers  several  millimeters  higher  than 
the  brachial.     In  the  prone  posture,  the  measurements  taken 


BLOOD-PRESSURE.  275 

at  either  point  approximate  each  other.  An  exception  to  this 
statement  is  noted  in  cases  of  aortic  regurgitation,  where  the 
femoral  pressure  is  30  or  more  degrees  higher  than  the 
brachial  in  the  prone  position.  The  blood-pressure  is  also 
higher  if  measured  through  the  clothing;  estimates  made 
when  the  cufT  is  applied  directly  to  the  arm  are  more  accurate. 

Estimation  of  Blood-pressure.  The  two  principal  factors 
upon  which  arterial  blood-pressure  depends  are:  (1)  the  force 
of  the  ventricular  contraction,  and  (2)  the  degree  of  peripheral 
resistance.  It  is  with  the  idea  of  estimating  these  factors 
that  we  employ  the  more  exact  mechanical  devices,  rather  than 
depend  upon  palpation  of  the  arteries,  which,  by  comparison, 
gives  results  that  are  at  surprising  variance  with  the  instru- 
mental records. 

By  compressing  the  bulb  of  the  apparatus,  we  increase  the 
pressure  within  the  cuff  to  a  point  a  few  degrees  above  that 
at  which  the  radial  pulse  disappears ;  gradually  allowing  the 
air  to  escape,  we  note  the  point  where  the  pulse  reappears ; 
this  is  the  systolic  pressure.  Carefully  watching  the  dial,  we 
observe  a  point  from  40  to  50  mm.  (1%  to  2  inches)  below  the 
high  systolic  reading,  where  the  greater  oscillation  of  the 
indicator  takes  place ;  this  is  called  the  diastolic  pressure.  The 
pulse-pressure  is  the  difference  between  the  two. 

The  above  method  is  g'enerally  used,  and  is  mentioned  here 
in  order  to  call  attention  to  its  inaccuracies,  introduced  by 
the  personal  equation,  and  to  condemn  it.  The  auscultatory 
method  of  Koratkow  is  the  only  method  of  reading  that  should 
be  employed,  and  is  accomplished  through  the  simple  maneu- 
ver of  placing  the  bell  of  a  stethoscope  over  the  bifurcation  of 
the  brachial  artery,  below  the  compressing  cuff.  As  the  bulb 
is  compressed  to  fill  the  cuff,  we  note  that  point  at  which  we 
first  hear  a  sound ;  continuing  the  inflation,  we  hear  a  gradual 
increase  of  sound,  which  as  gradually  disappears ;  note  the  dis- 
appearing point.  These  observations  made  on  the  "up-stroke" 
of  the  indicator  confirm  those  now  to  be  secured  on  the  "down- 
stroke."  Compress  the  bulb  a  little  farther,  and  then  begin 
the  gradual  reduction  of  the  air.  Note  the  point  at  which  the 
loud  sound  first  appears,  which  registers  the  "systolic"  pressure ; 
the  point  at  which  this  clear  sound  becomes  muffled  is  called  the 
"diastolic"  pressure. 


276      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

Importance  of  C omparativc  Readings.  For  some  inexplica- 
ble reason,  sphygmomanometry  is  rarely  practised  in  a  sys- 
tematic manner.  It  never  occurs  to  many  physicians,  who 
take  the  temperature  of  a  patient  at  each  visit,  to  estimate  the 
blood-pressure  as  frequently.  It  is  in  the  comparative  study 
of  frequent  blood-pressure  estimates  that  its  value  to  both 
patient  and  ph3'sician  lies ;  cursory  and  perfunctory  examina- 
tions are  worse  than'  useless,  in  that  they  mislead.  As  an  ex- 
ample of  the  value  of  repeated  readings,  it  has  been  discovered 
in  the  toxemia  of  pregnancy  that  a  gradual  and  progressive 
rise  in  systolic  pressure  is  of  grave  significance,  and  calls  for 
energetic  treatment.!^  When  we  have  a  similar  frequency  of 
observations,  reported  from  a  number  of  diseased  conditions 
by  a  number  of  careful  physicians,  the  subject  of  blood-pres- 
sure may  be  put  upon  a  scientific  basis. 

Normal  Standards.  A  study  of  the  many  tables  that  have 
been  suggested,  whereby  we  may  arrive  at  the  average  stand- 
ard of  blood-pressure  for  a  given  age,  seems  to  establish  the 
estimates  of  Faught  as  normal  standards.  He  gives  the  sys- 
tolic pressure  in  a  youth  of  20  years  as  being  120;  one  degree 
is  added  for  each  two  years  of  life;  a  normal  variation  of  17 
in  either  direction  is  permitted;  in  women,  the  record  is  10 
mm.  (0.3937  in.)  lower  than  in  men. 

A  normal  ratio  of  systolic,  diastolic,  and  pulse-pressure  is  be- 
lieved to  exist  in  health;  it  is  called  the  "1-2-3"  ratio,  in  which 
the  diastolic  pressure  is  twice  the  pulse-pressure;  the  systolic 
pressure  is  three  times  the  pulse-pressure. 

One  should  not  lose  sight  of  the  exclusion  value  which  at- 
taches to  a  normal  blood-pressure  reading  in  a  patient.  It  aids 
us  in  excluding-  from  a  consideration  of  the  case  those  diseases 
in  which  hypertension  is  quite  constant  in  the  clinical  picture. 

Significance  of  Pressures.  Despite  the  many  ingenious  in- 
terpretations which  have  been  placed  on  systolic  readings, 
high  blood-pressure  is  not  a  disease.  It  may  often  be  an  ex- 
pression of  an  attempt  to  maintain  a  physiologic  balance  on  the 
part  of  nature ;  we  cannot  emphasize  this  conviction  too  strongly. 
Temporary  rises  observed  in  pain,  neurasthenia,  excitement, 
or  after  exercise,  bear  out  this  contention ;  in  arteriosclerosis 
it  is  nature's  method  of  supplying  blood  to  vital  tissues  which 
may  be  more  or  less  ischemic  owing  to  capillary  fibrosis. 


BLOOD-PRESSURE.  ^77 

Hypertension  usually  exists  in  toxemia,  nephritis,  arterio- 
sclerosis, aortic  regurgitation,  cardiac  hypertrophy,  aneurysm, 
meningitis,  exophthalmic  goiter,  and  syphilitic  aortitis.  Hypo- 
tension, or  lowered  systolic  pressure,  is  observed  in  Addison's 
disease,  tuberculosis,  shock,  hemorrhage,  and  asthenic  pneu- 
monia. In  the  past,  but  little  significance  has  been  attached 
to  diastolic  readings,  but  the  value  of  this  method  of  estimating 
the  degree  of  peripheral  resistance  is  now  being  appreciated, 
and  promises  to  exceed  systolic  estimates  in  adding  to  the 
clinical  knowledge  of  the  future. 

Sphygmomanometry  has  not  proved  its  right  to  be  considered 
as  an  indication  of  the  functional  capacity  of  the  myocardium, 
regardless  of  the  contentions  of  its  ardent  advocates,  and  des- 
pite the  vague  general  opinion  to  that  effect.  Our  hope  for  a 
means  by  which  we  can  clinically  determine  the  functional 
capacity  of  the  all-essential  heart-muscle  lies,  at  present,  in  the 
determined  strides  which  electrocardiography  is  making  in 
this  direction,  and  in  the  possible  detection  of  a  value  existing 
in  the  ratio  of  the  first  sound  of  the  heart  as  compared  with 
the  second. 

We  have  purposely  omitted  from  this  article  any  of  the 
innumerable  "formulas"  by  which  a  mathematician  may  arrive 
at  a  calculated  estimate  of  cardiac  efficiency  by  blood-pressure 
figures ;  none  have  so  far  been  adduced  which  can  stand  the 
lime-light  of  clinical  investigation ;  nor  is  it  likely  that  depend- 
able formulae  can  be  thus  contrived  when  one  considers  the 
many  factors  in  addition  to  cardiac  muscular  action  which 
enter  into  the  complex  phenomena  of  blood-pressure. 

A  word  of  protest  should  be  added  against  the  practice  of 
telling  patients  that  they  "have  a  high  blood-pressure."  Re- 
marks similar  to  this  frequently  cause  much  distress,  and 
until  such  a  time  as  the  profession  better  understands  the 
significance  of  high  blood-pressure,  so  that  we  may  more  in- 
telligently interpret  it  for  our  patient,  we  are  in  the  position 
of  the  blind  leading  the  blind. 

TREATMENT    OF    HYPERTENSION. 

As  the  reader  has  already  probably  gathered  from  the  pre- 
ceding consideration,  the  indications  for  administering  vas- 
cular sedatives  are  rare  indeed.     Rest  in  bed ;  freedom  from 


278      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

anxiety,  depressing  emotions,  and  excitement;  free  catharsis 
by  the  use  of  saline  purges,  given  in  small  doses,  and  fre- 
quently repeated;  elimination  by  the  kidneys  and  by  the  skin, 
will  do  as  much  to  reduce  hypertension,  and  do  it  far  more 
safely,  than  will  the  employment  of  drugs.  Attention  will,  of 
course,  be  given  to  the  diet,  which  should  be  carefully  selected, 
and  of  a  limited  quantit}'.  Foods  that  contain  a  high  per- 
centage of  protein  are  interdicted,  familiar  examples  of  which 
are  meat,  eggs,  fish,  shellfish,  fowl,  cheese,  peas,  and  beans. 
When  emergenc}-  demands,  venesection  may  be  indicated. 
Drugs  are  employed  only  in  exceptional  instances,  their  power 
for  good  being  questioned,  and  their  possibility  for  harm  in 
other  directions  being  g-enerally  admitted. 

THE  USE  OF  CARDIAC  DRUGS. 

"When  called  to  guide  a  patient  through  an  illness,  the 
physician  should  be  constantly  a  watchman,  and  a  therapeutist 
only  when  necessity  arises"  (Hare).  The  drugs  which  have 
been  used  in  cardiovascular  disease  are  legion ;  those  of  proved 
efficiency  are  few.  Remedies  affecting  the  heart  indirectly  by 
their  effect  upon  other  organs  cannot  be  considered  as  cardiac 
drugs.  In  this  consideration  we  will  concern  ourselves  with 
remedies  of  demonstrated  value,  leaving  for  future  clinical 
and  graphic  researches  the  final  verdict  as  to  whether  there 
shall  be  included  among  dependable  cardiac  remedies 
those  drugs  which  have  been  administered  empirically  in  the 
past. 

The  newer  remedies,  such  as  epinephrin  and  pituitar}"  ex- 
tract, are  cardiac  potentialities,  and  as  such  will  here  receive 
the  mention  which  they  have  so  far  earned.  Drugs  of  time- 
honored  administration,  to  which  present  investigation  at- 
taches little  cardiac  effect,  receive  a  brief  allusion. 

Digitalis.  This  sovereign  heart-remedy  was  first  broug"ht 
to  the  attention  of  the  profession  by  Withering,  who  wrote 
"An  Account  of  the  Foxglove"  in  1785.  It  is  inter- 
esting to  note  the  astute  observations  of  this  pioneer,  who, 
in  speaking  of  the  diuretic  action  of  the  drug,  avers 
that  "Digitalis  seldom  succeeds  in  men  of  great  natural 
strength,  of  tense  fibre,  of  warm  skin,  of  florid  complexion,  or 


CARDIAC    DRUGS.  279 

in  those  with  a  tight  and  cordy  pulse.  If  the  belly  in  ascites 
be  tense,  hard,  and  circumscribed,  or  the  limbs  in  anasarca 
solid  and  resisting',  we  have  but  little  hope.  On  the  contrary, 
if  the  pulse  be  feeble  and  intermitting,  the  countenance  pale, 
the  lips  livid,  the  skin  cold,  the  swollen  belly  soft  and  fluctuat- 
ing, or  the  anasarcous  limbs  readily  pitting  upon  pressure  of 
the  finger,  we  may  expect  the  diuretic  effects  to  follow  in  a 
kindly  manner."  With  what  prophetic  foresight  he  thus  con- 
firmed the  observations  of  today,  when  he  allowed  but  little 
value  tO'  the  drug  in  arteriosclerotics  with  high  arterial  pres- 
sure and  associated  dropsy,  and  in  admitting  a  beneficial  ac- 
tion in  the  clinical  picture  of  auricular  fibrillation  which  he  has 
so  well  painted !  Controversial  storms  must  have  waged 
around  Withering's  head,  for  in  closing  his  preface  he  seeks 
the  solace  of  saying:  "After  all,  in  spite  of  opinion,  prejudice, 
or  error,  time  will  fix'  the  real  value  upon  the  discovery,  and 
determine  whether  I  have  imposed  upon  myself  and  others,  or 
contributed  to  the  benefit  of  science  and  mankind." 

Digitalis  is  derived  from  the  dried  leaves  of  the  perennial 
Digitalis  purpura,  or  Foxglove,  collected  from  plants  of  second- 
year  growth  as  they  are  about  to  flower.  While  many  gluco- 
sides  have  been  separated  by  chemists,  the  drug  does  not  have 
an  "active  principle"  that  is  universally  admitted.  The 
true  therapeutic  effect  of  the  remedy  is  best  secured  by  the 
employment  of  a  physiologically  tested  tincture  or  infusion, 
which  combines  all  of  the  qualities  claimed  for  several 
"isolated  principles."  The  employment  of  "digitalis  deriva- 
tives" may  account  for  the  absence  of  digitalis  results  occasion- 
ally complained  of  by  physicians.  This  statement  is  not  to  be 
construed  as  expressing  an  unfavorable  opinion  of  standardized 
tinctures  or  extracts  as  prepared  by  reputable  houses ;  it  is 
intended  to  convey  the  conviction  that  alleged  "digitalis-active 
principles"  do  not  give  satisfying  digitalis  results,  any  more 
than  do  the  stale  tinctures  occasionally  dispensed.  It  should 
be  the  custom  of  physicians  who  see  many  heart  cases  to  select 
a  physiologically  tested  and  standardized  tincture  of  digitalis, 
as  prepared  by  any  one  reputable  pharmacist,  and  at  the  same 
time  to  assure  himself  of  the  potency  of  the  hypodermic  tablet 
which  he  proposes  to  use ;  by  employing  these  two  prepara- 
tions to  the  exclusion  of  others,  he  soon  becomes  familiar  with 


280      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

the  results  to  be  expected  from  a  given  dose,  and  becomes 
adept  in  the  skillful  employment  of  his  remedy. 

When  employed  in  hearts  of  disturbed  mechanism,  the 
physiologic  effect  of  digitalis  in  therapeutic  dosage  is  shown 
in  (1)  decreased  atrioventricular  conduction;  (2)  increased 
force  of  the  ventricular  contraction.  By  decreasing  the 
conductivity  of  the  A-V  node,  it  slows  the  pulse  and 
lYicreases  the  length  of  diastole ;  by  increasing  the  force  of 
the  ventricular  contraction,  it  increases  the  pulse  force  and 


^ 

IP 

1 

m 

1 

^Pnr 

^^^^^=± 

i 

if 

i4i 

t 

mr 

3§| 

III 

m 

S5 

^ttt 

Fig_  19. — Influence  of  Digitalis  on  the  Electrocardiogram. 

The  leads  in  these  figures  are'  arranged  horizontally,  the  reverse  of  the  usual 
order  for  ease  of  comparison.  (A)  Control  curve.  Before  administering  digitalis 
(B)  After  1.4  Gm.  of  digitalis  had  been  given.  Note  (a)  diminution  m  height  or 
T-wave;  (&)  downward  slope  from  end  of  R  or  S  to  T.  (<■)  This  curve,  taken 
nineteen  days  after  the  drug  was  discontinued,  is  one  of  a  series  which  shows  a 
gradual  return  to  normal,  and  is  the  first  of  said  series  to  virtually  reproduce 
the  control  curve  A.  (Courtesy  of  Dr.  Alfred  E.  Colin,  of  the  Rockefeller  Insti- 
tute for  Medical  Research.) 

raises  arterial  pressure.  We  are  fully  aware  of  the  mass  of 
literature  relating  to  the  action  of  the  drug  on  the  pneu- 
mo-gastric  nerve,  on  the  sympathetic  fibres,  and  on  the  arter- 
ioles ;  we  feel  that  emphasis  of  the  physiologic  action,  already 
briefly  stated,  is  quite  sufficient  for  the  purposes  of  the 
clinician  who  would  administer  the  drug  understandingly. 


CARDIAC    DRUGS. 


281 


In  the  form  of  the  infusion,  digitalis  is  prized  as  a  remedy 
to  relieve  dropsical  effusions.  This  it  does  by  removing-  the 
congestion  of  the  kidneys  and  by  improving  the  blood-supply 
to  these  organs,  rather  than  by  any  action  on  the  renal  cells. 
By  thus  improving  the  circulation  of  the  kidneys,  it  is  a  de- 
pletant  of  accumulated  body  effusions. 

No  definite  limit  can  be  placed  on  the  amount  of  digitalis 
necessary  to  produce  and  maintain  a  desired  physiologic  re- 
sult. The  old  rule  of  "giving  the  drug  until  the  pulse  becomes 
regular"  has  probably  been  responsible  for  many  deaths  by 
inducing  heart-block,  and  v^ould  seem  to  explain  the  "cumu- 
lative action"  and  "digitalis  deaths"  of  medical  literature. 
When  we   recall  that  the   investigations   of  Cohn^*^   demon- 


Fig.  20. — Digitalis  Coupling  in  Auricular  Fibrillation. 

The  cardiac  rate,  previously  150,  under  full  doses  of  digitalis,  has  been  re- 
duced to  slightly  above  60.  A  pulse  deficit  of  40  has  been  reduced  to  nil.  The 
tendency  to  pairing  (or  tripling)  of  the  pulse-beats  is  clearly  shown.  Digitalis 
should  be  discontinued.     (Courtesy  of  Dr.  Ross  7.  Patterson.) 


strated  that  in  some  instances  digitalis  affected  the  heart 
within  thirty-six  hours  of  its  administration,  and  that  the 
effect  persisted  as  long  as  twenty-two  days  after  with- 
drawal of  the  drug,  we  can  appreciate  how  unreasoning  abuse 
of  the  remedy  would  induce  not  only  heart-block,  but  complete 
exhaustion  of  the  laboring  ventricle  as  well.  (See  Fig.  19.) 
Fairly  dependable  symptoms  of  physiologic  tolerance  are 
nausea,  vomiting,  and  headache,  but  unfortunately  these  symp- 
toms are  not  reliable  guides,  as  they  may  ensue  after  the 
first  dose,  may  not  set  in  for  several  days,  or  may  utterly  fail 
to  appear.  With  ordinary  physical  signs  to  guide  him,  the 
clinician  should  revise  the  initial  dosage  of  digitalis  (1)  upon 
the  appearance  of  a  first  sound  of  good  muscular  qual- 
ity at  the  apex ;  (2)  upon  the  appearance  of  a  gradual  equality 
in  the  ventricular  and  radial  rates  in  cases  of  auricular  fibrilla- 


282      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

tion — in  other  words,  when  the  pulse  deficit  is  only  ten  points 
less  than  the  simultaneously  counted  rate  at  the  apex — admin- 
istration of  the  drug  should  be  carefully  guarded ;  (3)  upon  the 
appearance  of  "digitalis  coupling,"  often  revealed  on  thought- 
ful radial  palpation,  in  patients  in  whom  the  drug  is  used. 
(Fig.  20.) 

It  is  almost  trite  to  remark  here  that  prolonged  use  of 
digitalis  over  periods  of  months  is  to  be  condemned,  unless 
frequent  professional;  observations  so  dictate.  One  patient 
recently  seen  had  been  taking  digitalis,  upon  his  own  initia- 
tive, for  a  year  and  a  half.  A  non-repetatur  upon  a  prescription 
will  save  a  physician  from  the  censure  attached  to  the  medical 
attendant  in  this  instance. 

Digitalis  is  the  remedy  par  excellence  in  auricular  fibrilla- 
tion, in  which  condition  its  chief  beneficial  effects  are  observed, 
and  upon  which  its  reputation  rests.  It  is  of  marked  value  in 
auricular  flutter.  Paroxysmal  tachycardia,  which  may  induce 
exhaustion  of  the  cardiac  muscle,  may  call  for  the  support 
afforded  by  this  drug,  as  also  may  alternation  of  the  heart. 
Heart-block  is  a  contraindication  to  digitalis,  unless  the  block 
be  complete,  in  which  latter  event  it  may  increase  cardiac 
tone.  Hypertrophy  and  dilatation  do  not  call  for  its  employ- 
ment, unless  circulatory  failure  ensues. 

If  the  physician  will  but  think  of  digitalis  as  a  drug  to  be 
used  only  when  especially  indicated  for  definitely  recognized  con- 
ditions, both  laity  and  profession  will  be  benefited  by  the 
thought.  The  detection  of  murmurs  does  not  call  for  digitalis, 
although  the  drug  may,  of  course,  be  indicated  in  valvular 
lesions  with  evidence  of  exhaustion  of  the  cardiac  muscle.  No 
drug  can  correct  a  chronic  valvular  lesion,  in  the  manner  that 
lubricating  oil  may  temporarily  correct  the  leaking  valve  of  a 
pump. 

Strophanthus.  This  drug  is  derived  from  the  seeds  of 
African  plants,  Strophanthus  hispidus  and  kombe.  It  is  similar 
to  digitalis  in  its  cardiac  action  as  clinically  observed;  experi- 
ments now  being  conducted  by  graphic  methods  will  give  us 
further  light  on  the  subject. 

Strophanthus  is  to  be  borne  in  mind  as  the  remedy  of 
choice  zvhen  digitalis  fails.  It  is  often  administered  to  those 
patients  who  have  an  idiosyncrasy  to  the  latter  drug,  or  in 


CARDly\C    DRUGS.  283 

whom  digitalis  produces  gastro-intestinal  symptoms — yet  it  is 
not  always  without  this  untoward  effect  itself.  If  given  to  a 
patient  who  has  previously  had  large  courses  of  digitalis,  it 
should  be  very  cautiously  employed. 

Tincture  of  strophanthus  is  given  in  doses  of  5  to  15 
minims  (0.3  to  1  Gm.)  t.  i.  d.  The  active  principle,  strophan- 
thin,  is  used  hypodermically  in  a  strength  varying  from  ^50 
to  %o  grain  (0.0004  to  0.0012  Gm.),  the  last-mentioned  dosage 
being  indicated  only  in  urgent  cases. 

The  Nitrites.  Nitroglycerin,  amyl  nitrite,  and  sodium 
nitrite  are  dependable  circulatory  aids  where  immediate  effect 
is  desired;  they  are,  however,  fleeting  in  character,  the  re- 
action not  being  long  sustained,  and  for  this  reason  are  ad- 
ministered at  three-  or  four-  hour  intervals. 

The  nitrites  cause  acceleration  of  the  pulse  by  a  reflex 
action  on  the  vagus  center  in  the  medulla.  There  is  no  ex- 
perimental proof  that  they  have  any  direct  action  upon  the 
heart-muscle ;  hence  a  much-damaged  myocardium  does  not 
contraindicate  their  employment  when  their  action  is  other- 
wise desired,  as  in  relieving  the  hypertension  of  angina  pec- 
toris. We  should  think  of  the  nitrites  as  relieving  arterial 
spasm,  for  it  is  in  this  direction  that  they  exert  their  most  pro- 
nounced therapeutic  effect.  The  value  of  this  form  of  medi- 
cation in  the  cardiovascular  failure  of  acute  infections,  such 
as  lobar  pneumonia,  is  to  be  also  borne  in  mind. 

The  dose  of  the  nitrites  is  as  follows :  The  spiritns  nitratis 
is  a  1  per  cent,  aqueous  solution  of  nitroglycerin,  and  is  given 
in  1-  or  2-  drop  (0.05  or  0.10  mil)  doses,  sometimes  gradually 
ascended.  Tablets  of  nitroglycerin  {tabellce  trinitrini)  each 
contain  %oo  grain  (0.0003  Gm.).  The  perles  of  amyl  nitrite 
contain  2  minims  (0.10  Gm.)  each,,  and  are  to  be  crushed  in  a 
handkerchief  and  inhaled  for  the  relief  of  arterial  spasm. 

Salvarsan.  To  include  the  recently  proven  antisyphilitics 
under  the  heading  of  Cardiac  Drugs  is  an  innovation ;  to 
exclude  them  from  the  classification  of  heart  remedies  would 
be  to  deny  the  gradually  accumulating  evidence  which  will 
eventually  determine  the  frequent  etiologic  relation  between 
syphilis  and  cardiovascular  disease.  The  preparation  and  ad- 
ministration of  salvarsan  and  neosalvarsan  are  described  under 
Aneurysm.     (See  p.  263.) 


284      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

The  lodids.  These  are  valuable  adjuncts  in  the  treatment 
of  circulatory  disorders,  either  through  their  alterative  effect 
or  by  virtue  of  their  action  in  specific  disease.  Under  Arte- 
riosclerosis administration  and  dose  are  discussed.  (See 
p.  272.) 

A  tropin.  This  alkaloid  of  belladonna  is  extracted  from  the 
roots  or  leaves  of  "Deadly  Nightshade."  Though  at  first 
slowing  the  heart  by  stimulation  of  the  vagus  center  in  the 
medulla,  this  slight  initial  eft'ect  soon  passes  oft',  and  the  heart- 
rate  increases,  owing  to  a  paralysis  of  the  terminal  inhibitory 
fibers  of  the  vagus  nerve.  Atropin  probably  increases  the  con- 
ductivity of  the  A-V  bundle ;  hence  it  is  the  remedy  indicated 
in  all  degrees  of  heart-block,  the  subcutaneous  dose  of  the  sul- 
phate being  3oO  grain  (0.0012  Gm.),  to  be  repeated  when  the 
eft'ect  has  disappeared.  The  action  of  the  drug  on  the  bundle 
neutralizes  the  effect  produced  by  giving  digitalis  in  excess. 

Tincture  of  belladonna  is  administered  in  the  dose  of  5  to 
40  minims  (0.3  to  2.6  Gm.).  The  drug  produces  drjmess  of 
the  fauces,  dilated  pupils,  sometimes  an  erythematous  rash, 
and  perhaps  a  talkative  delirium,  in  full  medicinal  dose — 
physiologic  eft'ects  to  be  discounted  by  the  physician  seeking 
a  cardiac  response,  and  yet  most  uncomfortable  symptoms, 
strenuously  objected  to  by  the  patient  who  is  to  take  the 
remedv  for  a  long  period. 

MorpJiin.  This  drug  slows  the  heart-rate,  not  by  a  direct 
action  upon  the  cardiac  muscle — for  there  it  has  no  eft'ect — but 
by  stimulation  of  the  A'agal  center.  Hence,  myocardial  lesions 
do  not  contraindicate  the  drug,  except  in  so  far  as  its  effects 
upon  other  parts  of  the  body  add  to  the  heart's  embarrassment ; 
morphin  checks  all  bodily  secretions  except  those  of  the  skin. 

The  pain  of  myocarditis  and  angina  pectoris,  the  rate  in 
tachycardias,  which  is  enhanced  by  excitement  and  restless- 
ness, the  intractable  insomnia  of  some  varieties  of  heart  dis- 
ease, and  the  dyspnea  of  others,  all  may  call  for  the  employ- 
ment of  morphin. 

]\Iorphin  sulphate  is  administered  in  doses  of  5^  to  % 
grain  (0.007  to  0.15  Gm.),  repeated  at  two-  or  three-  hour  in- 
tervals, until  the  desired  result  is  secured.  When  indicated  at 
all,  morphin  is  indicated  to  effect.  To  curtail  the  full  thera- 
peutic value  of  the  drug  by  an  arbitrary  limit  of  dose  is  an 


CARDIAC   DRUGS.  285 

error  of  judgment  too  frequently  seen — an  error  which  time 
may,  perhaps,  eradicate  from  the  professional  mind. 

Epinephrin.  This  drug  is  indicated  where  there  is  evidence 
of  acute  circulatory  collapse,  with  falling  blood-pressure.  It 
is  fleeting-  in  action,  and  should  not  be  used  where  a  sustained 
circulatory  effect  is  desired.  Janeway  used  a  large  dose  of 
4  mils  (1  dram)  of  a  1  :  1000  solution  with  most  amazing  re- 
sults, in  the  restoration  of  a  patient  apparently  moribund. 

Pituitary  Extract.  This  is  similar  in  action  to  epinephrin, 
the  difference  being  in  degree.  The  former  drug,  while  slower 
in  .action,  and  less  decided  in  effect,  maintains  its  circulatory 
stimulation  for  a  longer  period  than  does  epinephrin.  Ex- 
tract from  tlTe  infundibular  portion  of  the  pituitary  gland 
manifests  the  greatest  physiologic  effect. 

Caffcin.  As  a  result  of  their  animal  experimentations,  Pilcher 
and  Sollmann^'''  conclude  that  caffein  causes :  (a)  cardiac 
stimulation ;  (&)  increase  of  heart-rate  not  due  to  vagus  de- 
pression ;  (c)  vasodilatation  through  peripheral  depression  of 
the  vasoconstrictor  mechanism ;  (d)  central  vasoconstrictor 
stimulation  to  be  generally  ineffectual.  From  this  we  deduce 
the  tenable  hypothesis  that  caifein  probably  accelerates  the 
heart  action  by  direct  stimulation  of  the  heart-muscle.  Caffein 
is  administered  in  dosage  of  from  2  to  4  grains  (0.12  to  0.25  Gm.). 

Drugs  of  Doubtful  Utility.  It  may  not  be  altogether  wise 
nor  judicious  to  discard  time-honored  remedies  whose  reputa- 
tion for  cardiac  efficiency  bears  the  medical  testimony  of  many 
generations  of  accustomed  usage ;  yet  it  is  quite  appropriate,  in 
this  age  of  scientific  investigation,  that  we  require  remedies  to 
meet  the  standards  set  for  them  by  other  remedies,  equally  as 
honored  by  age  and  by  accustomed  usage,  which  show  their 
action  in  a  manner  satisfying  to  a  laboratory  investigation.  If 
practising  physicians  will  avail  themselves  of  the  proven  drugs, 
and  if  the  coming  generation  of  medical  men  will  avoid  the  use 
of  remedies  now  placed  under  the  ban  of  cardiologists,  then 
will  cardiac  therapy  advance  immeasurably  as  the  future  neces- 
sity for  detailed  clinical  and  graphic  study  is  thus  made  plain. 

Alcohol  raises  for  a  few  moments  the  systolic  pressure,  and 
thus  acts  as  an  apparent  circulatory  stimulant ;  it  cannot,  how^- 
ever,  be  regarded  as  a  true  circulatory  stimulant,  inasmuch  as 
it  decreases  cardiac   efficiency,  raises   disproportionately   the 


286       DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

diastolic  pressure,  and  lowers  pulse-pressure,  according  to  the 
exhaustive  investigations  of  Lieb,is  corroborated  by  many 
others.  Alcohol  is  no  longer  considered  a  food,  for  it  has  been 
determined  that  its  oxidation  in  the  body  is  a  protective  oxida- 
tion (as  is  that  of  uric  acid,  xanthin  bodies,  leucin,  etc.)  ;  it  is 
not  oxidized  for  the  purpose  of  being  used  by,  or  stored  up  in, 
the  economy  as  a  food.i^ 

Ammonia  reduces  heart-rate  by  reflex  nervous  inhibition. 
The  effect,  when  it  does  appear,  rarely  lasts  longer  than  a  few 
minutes. 

Camphor  affords  no  direct  evidence  whatever  that  it  favor- 
ably aft'ects  the  heart-muscle.  Its  use  in  auricular  fibrillation, 
from  recent  reports,  makes  it  of  doubtful  value  in  that  con- 
dition. 

Strychnin.  Newburgh,20  in  his  experiments  on  patients, 
found  that  none  were  benefited  by  strychnin;  compensation 
was  not  improved  in  the  slightest;  and  he  concludes  that 
neither  pharmacologic  nor  clinical  evidence  justifies  its  use 
in  the  treatment  of  either  acute  or  chronic  heart  disease.  Pil- 
cher  and  Sollmann^i  shoM^ed  that  str}^chnin  had  no  effect  upon 
the  heart ;  that  it  had  no  direct  action  upon  the  blood-vessels ; 
that  it  produced  no  marked  eff"ect  upon  blood-pressure. 
Despite  these  observations,  it  is  quite  possible  that  the  bene- 
ficial results  of  str}'chnin  administration  may  be  due  to  the 
action  of  the  drug  in  improving  systemic  tone. 

THE    NAUHEIM    BATHS. 

Balneotherapy  in  the  treatment  of  chronic  diseases  of  the 
heart,  as  introduced  by  Prof.  Dr.  Theodor  Schott,  of  Bad- 
Nauheim,  has  been  the  center  of  many  storms  of  professional 
opinion  as  to  its  therapeutic  value.  That  the  employment  of 
these  baths  has  proven  efficient  in  many  cases  of  cardio- 
vascular disease  is  supported  by  a  wealth  of  clinical  observa- 
tions; any  work  on  the  treatment  of  heart  disease  that  does 
not  give  to  the  subject  that  consideration  to  which  a  multi- 
tude of  successful  results  entitles  it,  would  be  incomplete.  In 
order  that  we  may  present  the  subject  as  its  distinguished 
sponsor  would  have  it  presented,  we  give  in  the  following 
pages  a  description  of  the  Nauheim  baths,  as  translated  by  Dr. 
S.  Lewis  Ziegler,  of  Philadelphia.-^ 


THE  NAUHEIM  BATHS.  287 

METHODS  OF  BALNEOLOGIC  TREATMENT. 

"Here,  as  is  often  the  case  in  medicine,  merely  general  rules 
can  be  formulated.  It  stands  to  reason  that  a  careful  physical 
examination  of  the  patient  must  be  made,  since  only  in  this 
way  can  a  strictly  personal  treatment  be  outlined ;  this  should 
never  be  disregarded,  because  these  baths  exert  a  most 
"decided  action  in  all  systemic  diseases,  and  especially  in  affec- 
tions of  the  heart.  According  to  the  method  of  application, 
favorable  results  may  follow,  just  as  readily  as,  conversely, 
unfavorable  effects  may  be  produced.  It  hasi  frequently  been 
emphasized  by  us  that  even  here  a  constant  control  by  the 
physician  is  essential.  The  symptoms  in  heart  affections  may 
undergo  sudden  chang'es,  and  especially  during-  balneologic 
therapy ;  it  is  therefore,  advisable  to  examine  the  heart  fre- 
quently before,  during,  and  after  the  bath.  The  methods  which 
have  proved  most  successful  in  my  hands  are  largely  the  fol- 
lowing : 

'Tt  is  best,  more  especially  with  severe  cases,  to  commence 
with  a  simple  salt-water  bath.  Since  the  water  at  Nauheim 
contains  between  2  and  3  per  cent,  of  sodium  chlorid  and  as 
much  calcium  chlorid  per  thousand,  it  may  be  necessary  to 
dilute  this  still  more.  The  duration  at  first  should  not  exceed 
eight  to  ten  minutes,  in  severe  cases  not  over  five.  The  tem- 
perature should  commence  at  93°  to  95°  F.  (33.8°  to 
35°  C),  and  should  be  reduced  but  slightly  during  the  first 
week.  One  must  be  specially  careful  with  anemic  and  weak 
patients,  and  with  those  who  are  easily  chilled.  On  the  other 
hand,  however,  even  in  patients  with  weak,  rheumatic  hearts, 
one  should  not  exceed  a  temperature  of  95°  F.  (35°  C), 
since  a  tonic  action  on  the  heart  will  not  be  gained.  It  is, 
therefore,,  preferable  to  administer  cooler  baths,  and  to  make 
them  of  shorter  duration.  In  the  first  half  to  one  minute  the 
patient,  while  remaining  quiescent,  may  experience  a  feeling 
of  chilliness;  then,  however,  a  sensation  of  full  comfort  should 
occur,  partly  owing  to  the  warming  action  of  the  bath  on  the 
skin,  and  partly  from  habituation.  If,  however,  after  a 
minute's  quiescence  this  does  not  result,  but  rather  the  slight 
feeling  of  cold  persists,  then  the  l)ath  must  he  slowlv  and 
carefully  warmed  to  a  temperature  which  is  just  sufficient  for 


288      DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 

the  purpose.  In  the  majority  of  cases,  as  the  cure  advances, 
cooler  and  cooler  temperatures  are  tolerated,,  and  may  be  used 
with  benefit. 

"One  should  avoid,  if  possible,  a  second  or  recurring  chill 
w^hile  in  the  bath.  By  this  we  understand  that  a  patient  who 
had  become  chilled  on  entering  the  bath,  had  later  regained 
his  warmth,  and  shortly  thereafter  had  commenced  to  feel 
chilled  again,  after  he  had  remained  quiet  for  some  time. 
Such  a  bath  was  too  prolonged  in  relation  to  its  temperature. 
The  temperature  should  either  be  rapidly  raised  or  the  patient 
should  leave  the  bath  at  once.  During  the  following  days 
warmer  baths  should  be  given. 

"Many  patients,  especially  those  who  suffer  readily  from 
dyspnea,  cannot  tolerate  complete  baths  at  first.  They  find 
the  pressure  over  the  cardiac  region  very  troublesome.  It  is 
best  to  recommend  that  such  persons  should  not  be  immersed 
in  the  water  deeper  than  to  the  level  of  the  nipples.  Grad- 
ually they  also  become  accustomed  to  the  full  bath.  Partial 
baths  may  easily  produce  ill  efifects,  and  should,  therefore, 
be  avoided.  Patients  suffering  from  heart  disease  should 
bathe  neither  on  an  empty  stomach  nor  on  a  full  one.  Most 
suitable  of  all  is  the  forenoon,  about  one  to  two  hours  after 
breakfast,  or,  if  this  cannot  be  arranged,  then  the  late  after- 
noon, from  three  to  four  hours  after  the  midday  meal. 

"If  the  baths  are  well  tolerated,  the  stronger  concentrations 
may  gradually  be  employed.  First,  the  concentration  of  the 
salts  should  be  increased,  especially  that  of  the  calcium 
chlorid.  At  Nauheim  we  obtain  this  by  the  use  of  the  mother- 
liquor  derived  from  the  spring,  which  contains  30  to  40  per 
cent,  of  calcium  chlorid.  After  these  follow  the  baths  con- 
taining carbonic  acid,  in  a  quiescent  state,  and  later  those  rich 
in  free  carbonic  acid  gas;  for  these  we  employ  at  Nauheim, 
in  rotation,  the  Thermal,  Thermal  effervescing,  and  Sprudel 
effervescing  baths,  as  well  as  the  eft'ervescing  flowing  or 
Strom-Sprudel  of  the  individual  springs,  with  their  different 
temperatures  and  their  varying  concentrations  of  salts  and 
carbon  dioxid. 

"Patients  with  heart  disease,  without  exception,  require 
days  of  rest,  on  which  the  bath  is  suspended ;  in  certain  in- 
stances, especially  with  severe  cases,  a  pause  day  is  necessary, 


THE   NAUHEIM    By\THS.  289 

even  after  the  first  day;  usually,  however,  after  the  second 
day.  Later,  three  or  four  l^aths  may  be  given  on  successive 
days.  Simultaneously,  an  extension  in  the  duration  of  the 
bath  also  takes  place ;  it  is,  however,  seldom  advisable,  par- 
ticularly in  severe  cardiac  lesions,  to  prolong  them  beyond 
eighteen  or  twenty  minutes.  After  each  bath  the  patient 
should  be  wrapped  in  hot  towelling,  and  rubbed  down  vigor- 
ously, so  that  the  skin  becomes  red  and  warm.  He  should 
then  resume  his  clothing,  and  immediately  seek  his  room, 
where  he  should  rest  in  bed  for  at  least  one  hour,  under  a  suit- 
able covering,  in  order  that  the  body  may  be  rested  and  main, 
tain  an  equable  warmth.  During  this  rest-period  the  mind 
should  be  kept  quiet,  and  all  reading  avoided.  In  the  further 
course  we  should  endeavor  to  obtain  a  continuous,  but,  never- 
theless, prudent  stimulating  action  of  the  baths.  The  baths 
should  be  given  always  slightly  cooler;  always  for  longer 
periods,  and  at  more  frequent  intervals.  An  exact  supervision 
by  the  physician  in  regard  to  this  should  be  constantly  exer- 
cised. The  result  of  today's  bath  is  the  criterion  for  tomor- 
row's orders. 

"Owing  to  their  strong  content  in  salt  and  carbonic  acid, 
the  Nauheim  baths  can  gradually  be  taken  fairly  cold,  and 
can  be  safely  borne  by  patients  with  cardiac  affections.  In 
this  way  there  is  a  possibility  of  hardening  such  sufferers, 
little  by  little,  in  order  to  make  them  resistant  toward  cold, 
and  particularly  toward  muscular  rheumatism,  which  is 
naturally  of  great  importance  for  heart  patients. 

"During  menstruation  the  baths  should  be  discontinued, 
as  an  abnormally  large  loss  of  blood  may  be  caused  by  such 
powerful  baths,  and  this  must  be  especially  avoided  in  cases 
of  heart  disease. 

"The  summer  months  are  the  most  suitable  for  balneotherapy. 
In  mild  cases,  from  three  to  six  weeks  are  sufficient,  to  which 
may  be  added  with  advantage  an  after-cure  in  a  moderately  high 
mountainous  district,  not  over  1CX)0  to  1200  meters  (3000  to 
4000  feet).  In  severe  cases,  on  the  other  hand,  the  treatment 
should  extend  over  several  months,  and  it  is  then  advisable  to 
divide  the  cure  into  two  parts,  and  to  separate  them  by  a 
short  residence  in  a  mountainous  region.  To  form  an  exact 
estimate  of  the  number  of  baths  at  the  beginning  of  treat- 


290      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

meiit  is  not  possible,  since,  apart  from  the  severity'  of  the  case, 
patients  react  quite  differently  to  the  baths.  It  can  be  readily 
understood,  therefore,  why  it  is  quite  out  of  the  question  to 
formulate  such  a  scheme.  During  the  winter  many  patients 
with  heart  disease  require  residence  in  a  southern  climate,  in 
order  to  remain  in  the  open  air  to  the  fullest  extent. 

"It  is  now  possible  for  those  suffering  from  heart  disease, 
who  are  not  in  a  position  to  take  the  cure  by  means  of  the 
natural  baths,  to  imitate  these  baths  at  home,  to  a  certain  ex- 
tent. My  brother  and  I  have  laid  down  exact  directions  to 
this  effect.  One  should  employ  for  this  purpose  preferably 
the  natural  Xauheim  bath  salts,  or,  if  these  are  not  available 
at  the  moment,  make  use  of  the  most  important  of  their 
saline  constituents,  namely,  sodium  chlorid  and  calcium 
cJiIorid,  in  the  correct  proportions— 2  per  cent,  of  the  former, 
and  1  part  per  1000  of  the  latter.  These  quantities  may  be 
increased  when  stronger  baths  are  indicated.  The  carbonic 
acid  is  best  obtained  from  sodium  bicarbonate  and  hydro- 
chloric acid;  both  are  used  in  the  form  in  which  they  exist 
in  commerce.  The  chemical  equivalents  indicate  in  what  pro- 
portion these  ingredients  are  to  be  added  to  the  bath.  AA^ith 
the  strong  solution  of  h3'drochloric  acid  (equivalent  to  42.8 
per  cent.)  equal  quantities  of  hydrochloric  acid  and  sodium 
bicarbonate  should  be  employed.  With  the  dilute  hydro- 
chloric acid  a  correspondingly  larger  quantity  of  this  solution 
is  necessar}'.  The  sodium  bicarbonate,  commencing  with  100 
grams  (3  oz.),  and  gradually  increasing  to  500  (15  oz.),  1000 
(30  oz.),  or  even  to  1500  grams  (45  oz.),  as  the  baths  progress, 
should  be  dissolved  in  the  bath-water  simultaneously  with  the 
other  salts  (sodium  chlorid  and  calcium  chlorid),  which  must 
also  be  increased  in  proper  proportions  for  these  stronger 
baths.  An  excess  of  bicarbonate  of  sodium  is  always  advis- 
able for  the  protection  of  the  bathtub.  After  the  temperature 
of  the  water  has  been  properly  regulated,  an  amount  of  hydro- 
chloric acid  equivalent  to  the  quantity  of  sodium  bicarbonate 
already  dissolved  in  the  bath  is  poured  directly  on  the  surface 
of  the  water  from  a  small-mouthed  bottle  and  distributed  well 
over  it.  One  should  avoid  any  additional  agitation  of  the  bath- 
water, as  otherwise  the  carbon  dioxid  Avill  readily  escape  into 
the  air.     The  layer  of  carbonic  acid  gas  which  forms  on  the 


THE  NAUHEIM    BATHS.  291 

surface  of  the  water  during  its  preparation  should  be  drixen 
ofif  with  a  towel  before  the  bath  is  used,  so  that  the  patient 
will  not  breathe  it.  In  this  way  the  carbonic  acid  gas  will 
continue  to  be  evolved  for  a  considerable  time,  prol^ably  a 
half-hour  or  more. 

"Instead  of  hydrochloric  acid  one  may  employ  a  milder  acid, 
as,  for  example,  formic,  citric,  or  tartaric  acid,  since  these  are 
less  liable  to  attack  the  sides  of  the  tub ;  of  course,  they  must 
also  be  added  in  amounts  corresponding  to.  their  respective 
equivalents  (about  2  parts  of  acid  to  1  part  of  sodium  bi- 
carbonate). 

"By  the  use  of  such  baths  as  these,  many  errors  have  be- 
come apparent.  For  instance,  it  is  lield  by  some  that  a  plain 
salt-water  bath,  or,  what  is  still  more  common,  a  plain  car- 
bonated bath,  is  sufficient  for  the  treatment  of  chronic  heart 
disease.  If  we  desire  to  obtain  an  increasing  tonic  action,  so 
far  as  may  be  possible  with  such  artificial  baths,  then  we  must 
even  here  increase  in  a  systematic  manner  the  dosage  of  the 
ingredients,  salt,  calcium  chlorid,  sodium  bicarbonate,  and 
hydrochloric  acid,  and  adjust  the  temperature  and  duration  of 
these  baths  to  the  condition  of  the  patient  at  the  time  being. 

"The  employment  of  the  ingredients  in  definite  and  fixed 
doses,  as  they  are  prepared  and  sent  out  by  certain  factories 
(known  as  "acid  cakes"),  has  led  to  the  evolution  of  carbon 
dioxid  in  improper  proportions,  and,  above  all,  to  the  quan- 
tity of  the  gas  increasing  by  leaps  and  bounds.  These  are 
positively  dangerous.  A  considerable  number  of  patients  have 
had,  as  I  have  been  able  to  convince  myself,  imperfect  or  un- 
toward results  from  the  fact  that  the  baths  formed  with  such 
prepared  doses,  owing  to  their  faulty  adjustment,  were  suit- 
able neither  for  the  case  as  such,  nor  for  the  temporary  con- 
dition of  the  sufferer. 

"It  is  self-evident  that  even  in  the  employment  of  artificial 
baths  a  constant  supervision  by  the  physician  is  essential,  if 
satisfactory  results  are  to  be  obtained.  And  often  a  g"Ood 
result  is  only  to  be  secured  when  it  is  practicable  to  remove 
the  patient  from  business  and  family  worries  into  pure  air 
and  new  surroundings.  Suitable  nourishment  also  plays  an 
important  part  in  these  cases.  If  properly  used,  favorable 
results  can  be  obtained  with  artificial   Nauheim  baths  in  a 


292      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

certain  proportion  of  cases.  Naturally,  the  number  of  cases 
to  be  benefited  must  necessarily  be  limited  by  the  circum- 
stance that  the  strongest  of  these  baths — the  effervescing  and 
the  effen^escing  flowing  baths — cannot  be  imitated  artificially." 

EXERCISES    IN    CHRONIC    HEART    DISEASE. 

For  those  cardiopaths  who  cannot  go  abroad  to  secure  the 
beneficial  results  which  follow  the  resistance  exercises  of 
Schott,  or  the  graduated  exercises  of  Oertel — a  method  of 
treatment  which  has  proved  most  successful  in  selected  cases 
— we  here  present  a  consideration  of  the  subject  which  will 
enable  the  general  practitioner  to  intelligently  carry  out  the 
principles  as  employed  at  Nauheim.^s 

Methods  of  Gymnastic  Treatment.  By  means  of  regulated 
gymnastic  exercises,  effects  can  be  obtained  similar  to  those 
of  balneotherapy.  The  bath  produces  its  action  by  way  of  the 
sensory  nerve-tracts;  the  gy^mnastics,  as  already  mentioned, 
througfh  other  nerve-tracts.  The  essential  characteristics  of 
the  gymnastics  are  as  follows :  The  movements  employed 
must  always  be  carried  out  slowly,  and  with  such  degree  of 
power  as  the  momentar}^  condition  of  the  patient  will  permit. 
In  order  to  procure  this  simultaneous  retardation  and  increase 
in  strength,  resistance  is  necessary,  which  is  supplied  by  a 
second  person,  the  "gymnast,"  or  operator;  this  is  the  simple 
passive  resistance  gymnastics.  Or,  the  resistance  is  produced 
by  the  patient  himself,  through  the  simultaneous  contraction 
of  antagonistic  muscles;  this  form  we  have  called  gymnastic 
exercises  with  self-resistance.  Regarding  the  employment  of 
gymnastics,  the  following  general  regulations  may  be  stated  :-■* 

1.  The  movements  should  alternate  with  one  another  in 
such  a  manner  that,  according  to  their  arrangement,  new 
groups  of  muscles  are  continually  being  brought  into  activity. 
After  the  movements  have  taken  place  over  the  whole  of  the 
skeletal  musculature,  they  can  eventually  be  repeated  in  sev- 
eral cycles  if  the  patient  still  feels  sufficientl)^  fresh.  In  this 
way  a  one-sided  fatigue  is  most  effectively  prevented. 

2.  This  general  activity  of  the  skeletal  muscles  can  be 
attained  by  means  of  a  very  simple  geometric  arrangement  of 
the  movements.    Usually  we  employ  the  following  scheme : 


EXERCISES   IN    CHRONIC   HEART    DISEASE.  293 

{A)  Movements  of  >the  extended  arms  in  three  vertical 
directions,  one  after  another. 

(a)  Sagittal,  toward  the  front  from  the  position  of  down- 
ward extension,  upward  to  near  the  temples,  and  from 
there  downward  again. 

(b)  Frontal,  laterally  upward  to  the  temples,  and  back- 
ward. 

(c)  Horizontal,,  brought  together  and  apart  again  in  a 
horizontal  direction, 

(d)  The  fully  extended  arms  are  rotated  on  their  axes 
outward  and  inward  to  the  farthest  extent,  which  includes 
pronation  and  supination. 

(B)  While  with  the  free  articulation  of  the  shoulder- joint 
a  selection  of  the  directions  of  movements  was  necessary, 
the  movements  for  the  elbow-joint  and  wrist  are  determined 
by  nature.  Flexion  and  extension,  with  radial  and  ulnar  ab- 
duction; the  rotations  have  already  been  carried  out 
under  (A). 

(C)  Movements  of  the  body,  bending  forward  from  as  far 
back  as  the  patient  can  bend,  and  the  reverse ;  side  move- 
ments from  the  extreme  left  to  the  extreme  right,  and  vice 
versa,  as  well  as  rotation  of  the  vertebral  column  on  its  axis, 
in  both  directions. 

(D)  The  extended  leg  should  be  raised  under  resistance, 
straight  forward  and  upward,  and  again  lowered  against 
resistance ;  then  again  to  the  right  and  to  the  left,  and 
raised  and  lowered  toward  the  back. 

{E)  The  directions  of  movement  for  the  knee-  and  ankle- 
joint  are  also  determined  by  nature. 
It  is  not  necessary  to  carry  out  all  of  the  movements  on 
each  occasion. 

3.  One  can  train  up  men  to  act  as  gymnastic  operators  in 
a  very  short  time,  if  they  have  sufficient  conscientiousness  and 
intelligence.  Of  course,  they  must  previously  have  gained  a 
certain  amount  of  anatomic  and  physiologic  knowledge.  It  is 
of  advantage,  in  many  cases,  to  teach  a  member  of  the  pa- 
tient's family,  so  that  the  sufferer  can  always  have  someone 
at  hand. 


294      DISEASES    OE    THE    CARDIOVASCULAR    SYSTEM. 

The  gymnastic  operator  must  learn : 

(a)  The  Application  of  Resistance.  According  to  the 
relation  of  his  strength  to  that  of  the  patient,  he  should 
apply  the  resistance  at  a  higher  or  lower  position,  in  the 
latter  case  with  the  advantage  of  greater  leverage  in  his 
favor.  The  resistance  should  always  be  applied  on  the 
advancing  side,  as,  for  example,  on  the  anterior  side  of 
the  forearm  when  the  two  arms  are  being  approached 
together  horizontally,  and  on  the  dorsal  side  when  they 
are  being  horizontally  separated  again  by  the  opposite 
movement.  Similarly,  on  the  upper  and  lower  leg  he  has 
to  exert  pressure  at  one  time  on  the  front,  at  others  on 
the  outer,  inner,  or  posterior  side  of  the  limb,  according 
to  the  momentary  direction  of  the  movement.  The  re- 
sistances for  the  bending  of  the  body  are  applied  in  front 
over  the  manubrium  sterni,  or  at  the  back  over  the  lum- 
bar vertebrae ;  those  for  extension  of  the  back  on  the  neck 
and  on  the  xiphoid  process.  To  check  the  rotation  of  the 
body,  the  operator  stands  at  the  side,  and  places  the  right 
hand  in  front  of  the  advancing  shoulder,  and  the  left  hand 
behind  the  retreating  shoulder,  and  so  on. 

The  operator  should  exert  pressure  on  one  side  only, 
and  never  grasp  the  limb,  because  he  may  thus  quite 
easily,  and  unconsciously,  prevent  the  movements  in- 
stead of  assisting  their  accomplishment  against  resistance. 

(&)  The  operator  must,  in  fact,  oommence  with  the  in- 
tention of  moving  the  limb  which  is  undergoing  exercise 
in  a  direction  opposite  to  that  in  which  it  is  being  directed, 
but  he  must  always  allow  the  patient  to  have  the  upper 
hand.  From  my  own  experience,  I  can  recommend  only 
these  so-called  eccentric  movements  for  patients  suffer- 
ing from  heart  disease. 

(c)  The  resistance  must  be'  so  calculated  that  the  move- 
ment may  succeed  in  a  slow  and  regular  manner,  but 
should  never  be  so  powerful  as  to  stop  the  movement 
completely  during  its  progress,  or  to  allow  it  to  progress 
only  by  fits  and  starts.  The  hand  of  the  operator  should 
always  exert  approximately  the  same  even  pressure  on 
the  patient's  limb  while  it  follows  the  limb  through  the 
movement. 


EXERCISES    1\    CllKONlC    HEART    JJISEASE.  295 

4.  While  the  previous  regulations  for  the  use  of  curative 
gymnastics  are  applicable  in  a  general  sense,  the  following 
must  be  added  as  the  most  important  for  the  treatment  of 
heart  diseases:  The  patient  should  be  exhorted  to  overcome 
the  resistance  so  slowly  that  his  breathing  will  remain  abso- 
lutely quiescent,  or,  as  I  usually  express  it,  so  that  he  shall 
have  enough  breath  left  in  order  to  speak  with  ease  at  all 
times.  The  operator  himself  must  observe  the  patient's  mouth 
and  nostrils  carefully;  any  trace  of  commencing  dyspnea  is  an 
indication  for  pausing  until  the  breathing  has  become  dis- 
tinctly quiet  again. 

If  necessary,  a  single  movement  may  be  divided  up  into 
several  sections,  between  which  the  limb  may  rest  while  sup- 
ported in  the  hand  of  the  gymnast ;  following  each  single 
movement  there  should  be  a  pause  of  one  to  three  minutes' 
duration,  and;  the  patient  may  sit  down  to  avoid  the  slightest 
tiring.  At  the  end  of  the  seance  the  patient  should  rest  quietly 
on  a  couch  for  about  fifteen  minutes. 

At  the  end  of  this  article  are  numerous  illustrations  of  the 
most  important  exercises,  from  which  may  be  observed  the 
positions  and  movements  of  the  patient,  and  of  the  operator 
as  well.  Bedridden  patients  can,  of  course,  carry  out  only  a 
few  of  these  exercises  in  the  supine  position.  In  other  cases 
standing  is  difficult,  so  that  those  exercises  only  are  possible 
which  can  be  practised  while  in  the  sitting  posture. 

Whereas  at  the  beginning  the  greatest  possible  care  is 
necessary,  as  the  treatment  progresses  more  powerful  resist- 
ance can  always  be  withstood  with  ever-shortening  pauses,  as 
the  heart  itself  becomes  more  vigorous  from  the  exercises. 

With  young  persons  who  are  in  process  of  rapid  growth, 
and  in  whom  the  chest  has  not  at  the  same  time  developed 
sufficiently,  and  likewise  in  persons  with  kyphosis  and  ad- 
vanced scoliosis,  the  heart  often  remains  weak,  and,  most  fre- 
quently of  all,  the  respiration  is  imperfect.  It  is  of  advantage 
to  employ,  in  these  cases,  breathing  gymnastics  with  deeper 
inspiration  and  expiration.  So  long  as  the  bones  and  rib 
cartilages  are  still  soft  and  elastic  it  is  possible  to  produce  ex- 
pansion of  the  chest  by  means  of  such  gymnastics,  and  to 
obtain  an  improvement  in  the  respiration  and  in  the  pulmonan- 
circulation,  and,  as  a  result,  an  invigoration  of  the  heart  also. 


296       DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 

In  cases  of  disturbance  of  the  peripheral  circulation,  or 
where  edema  has  already  occurred,  massage  may  be  emplo3'ed 
with  good  results.  This  consists  best  of  all  in  centripetal 
stroking  of  the  extremities,  in  the  form  of  "effleurage"  and 
"petrissage,''  in  order  to  facilitate  the  return  of  the  blood  to 
the  heart,  and  also  the  absorption  of  the  edematous  fluid.  In 
cases  in  which  there  is  increased  rapidity  of  the  heart's 
action,  "fapotement,"  which  is  usually  carried  out  on  the  body, 
together  with  the  employment  of  an  ice-bag,  produces  a 
rapidly  sedative  effect;  this  action,  however,  does  not  usually 
last  very  long.  The  same  remark  applies  to  vibrator}'  mas- 
sage, which  is  often  employed  nowadays  instead  of  manual 
massage.  The  action  of  this  vibration  massage  is  also  in- 
sufficient and  of  short  duration,  even  when  it  is  carried  out 
in  conjunction  with  high-frequency  currents.  This  has  been 
frequently  confirmed  from  other  quarters,  as,  for  example,  in 
a  work  recently  published  by  Plate  and  Bornstein. 

AA'e  have  also  recommended  the  application  of  heat  in  cases 
of  weakness  of  the  cardiac  muscle,  in  which  the  heart  re- 
quires a  more  rapid  stimulation.  Best  of  all  is  the  use  of 
hot  water,  in  a  rubber  bag,  at  a  temperature  between  1-K)°  F. 
(60°  C.)  and  160'  F.  (71.1°  C),  which  should  be  applied 
lightly  to  the  region  of  the  heart. 

The  mechanical  treatment  of  heart  disease  in  the  form  of 
gymnastics  and  massage  has  been  specially  cultivated  in 
Sweden.  The  fact  that  these  methods,  discovered  and  de- 
veloped in  an  empiric  manner,  have  clung  to  hard-and-fast 
rules,  had  confined  their  use  to  that  country  alone,  until  the 
work  of  AMde  and  others  caused  them  to  be  slowly  taken  up 
by  other  nations. 

The  Swedish  movements  first  obtained  general  dissemi- 
nation through  their  talented  advocate.  Zander,  who,  along 
with  manual  treatment,  employed  also  very  cleverly  con- 
structed apparatus,  which  forms  a  distinct  acquisition  to  our 
curative  stores.  ]\Iuch  that  has  already  been  described  as  to 
the  action  of  resistance  gymnastics  applies  also  to  the  machine 
gymnastics  of  Zander.  These  apparatuses  are  intended  to 
make  the  patient  independent  both  of  the  gymnastic  operator 
and  also  of  his  own  ph^-sical  condition.  As  to  the  latter  state- 
ment, opinions  are  divergent. 


EJt^RCISES   IN   CHRONIC   HEART    DISEASE.  297 

A  constant  supervision  is  very  necessary  with  machine 
gymnastics,  as  much  on  account  of  the  reguhition  of  the 
resistance  as  also  to  note  the  condition  of  the  patient  during 
and  after  the  movements.  But  even  with  an  exact  control 
by  the  physician,  it  is  impossible  to  equalize  the  imperfections 
which  exist  in  the  nature  of  the  machine.  If  the  resistance  is 
at  first  made  too  great,  the  patient  must  endeavor  to  overcome 
this  resistance  during  the  whole  period  of  the  movement.  An 
exact  individualization,  or  even  an  increase  or  diminution 
during  a  single  movement,  cannot  be  attained;  the  machine 
docs  not  adapt  itself  to  the  case.  A  resistance  which  at  one 
time  was  correct  may  become  far  too  great  on  the  repetition 
of  the  movement,  owing  to  the  rapidly  changing  condition  of 
the  diseased  heart.  Machine  gymnastics  may,  therefore,  be  a 
source  of  danger  to  the  patient,  and  in  fact  overstraining  is 
not  uncommonly  observed  after  their  use.  At  the  same  time, 
Zander's  machines  are  unquestionably  a  great  advance  on  the 
many  one-sided  apparatuses,  such  as  the  ergostat  and  several 
others. 

Some  years  ago,  by  the  employment  of  a  wheeL  mounted 
eccentrically,  as  well  as  by  weights  moving  on  inclined  planes, 
Herz  improved  the  apparatus  of  Zander;  his  apparatus  was 
also  considerably  used.  The  expensiveness  and  need  of 
management  for  Zander's  and  for  Herz's  apparatuses,  and  the 
circumstance  that  for  their  use  the  patients  are  limited  to 
place  and  time,  stand  in  the  way  of  their  general  employment. 

Oertel,  who  at  one  time  gave  a  great  impetus  to  the  treat- 
ment of  heart  diseases,  combined  with  his  mechanical  treat- 
ment a  dietetic  therapy,  which  consisted  principally  in  a 
limitation  of  the  quantities  of  fluid.  We  shall  discuss  here 
merely  his  mechanical  method  of  treatment.  Oertel  employed 
in  his  method  the  movements  of  walking  and  climbing,  and 
hoped  that  this  increased  muscular  activity  would  produce  an 
invigoration  of  the  heart,  and  a  removal  of  the  circulatory  dis- 
turbances. For  these  climbing  exercises,  Oertel  selected 
mountainous  regions — "Tcrraiukurortc,"  as  he"  called  them — 
which  were  suitable  for  his  purpose  by  reason  of  theii  ascend- 
ing paths.  So  long  as  it  is  a  matter  of  treating  3^oung  and 
muscularly  strong  persons,  of  a  rugged  physique,  good  results 
can  certainly  "be  obtained  by  this  method;  but  with   definite 


298      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 

heart  disease^  however,  whether  of  an  organic  or  functional 
nature,  cHmbing  is  an  uncontrollable  form  of  gymnastics 
which  cannot  be  administered  in  definite  dosage,  and  which 
cannot  be  used  at  the  beginning,  but  only  at  the  end,  of  the 
treatment,  when  the  heart  has  become  so  far  invigorated 
through  other  methods  of  treatment  that  it  can  undertake  such 
extra  exertion  as  hill-climbing  requires,  without  any  actual 
danger. 

GYMNASTIC    POSES    FOR   RESISTANCE 
EXERCISES. 

]\Iany  of  the  resistance  exercises  have  been  described  and 
illustrated  in  various  publications,  and  here  is  presented  on 
the  pages  that  follow  an  orderly  resume  of  the  various  differ- 
ent movements  devised  by  the  originator  of  the  method.  The 
very  practical  plan  has  been  adopted  of  exhibiting  photo- 
graphic reproductions  of  the  actual  gymnastic  movements,  as 
posed  by  two  trained  operators  who  have  had  long  experience 
in  this  class  of  w^ork.  While  these  illustrations  do  not  cover 
all  the  movements  that  can  be  executed,  a  quite  general  selec- 
tion has  been  made  in  order  to  elucidate  the  subject  as  fully 
as  possible. 

The  principles  already  laid  down  have  been  adopted  by 
ourselves  and  accepted  by  our  colleagues,  and  are,  therefore, 
the  present  governing  standards.  Wt  will,  however,  briefly 
recapitulate  a  summary  of  the  more  important  regulations 
which  govern  these  passive  resistance  exercises : 

1.  Passive  resistance  movements  include  abduction,  adduc- 
tion, flexion,  extension,  and  rotation  in  a  vertical,  horizontal, 
or  lateral  direction. 

2.  These  movements  should  so  alternate  that  new  groups 
of  muscles  are  continuousl)-  made  to  act  in  sequence,  thus 
avoiding  fatigue. 

3.  The  resistance  should  be  made  by  the  operator  as 
slow]}'  and  gently  as  possible,  but  with  as  much  firmness  and 
muscular  power  as  the  patient's  physical  condition  will 
warrant. 


Gymnastic  poses  for  resistance  exercises.  299 

4.  The  operator  should  never  grasp  the  patient's  limb 
tightly,  but  should  oppose  its  movement  by  firm  counter- 
pressure  against  the  advancing  side,  thus  retarding  the  move- 
ment, but  always  permitting  the  patient  to  retain  the  "balance 
of  power." 

5.  The  operator  should  change  his  resistance  whenever 
the  direction  of  the  physical  force  is  changed. 

6.  To  orain  a  well-balanced  and  uniform  effect,  these  exer- 
cises  should  always  be  bilateral. 

7.  The  operator  should  closely  watch  the  patient's  breath- 
ing and  circulation,  and  at  the  slightest  sign  of  embarrassment 
should  stop  the  exercises.  The  patient  should  never  be 
allowed  to  hold  his  breath  while  exercising. 

8.  A  pause  of  one  or  two  minutes  should  be  allowed  after 
each  exercise  in  order  to  avoid  any  fatigue.  The  patient  may 
sit  down  during  the  pause,  especially  during  the  latter  half  of 
the  seance. 

9.  The  length  of  time  devoted  to  each  seance  should  be 
about  a  half-hour.  At  the  end  of  that  period  it  will  frequently 
be  found  that  the  number  of  heart-beats  has  been  reduced 
from  10  to  15  per  minute,  and  that  the  area  of  cardiac  dullness 
has  been  made  to  contract  an  inch,  more  or  less. 

10.  After  the  seance  is  finished,  the  patient  should  rest 
quietly  on  a  couch  for  at  least  fifteen  minutes. 

This  resting  period  is  an  essential  detail  of  the  Schott 
treatment  that  should  never  be  abridged  nor  omitted.  As  a 
rule,  the  patient  experiences  a  sense  of  moderate  fatigue  after 
the  completion  of  the  exercises,  and  in  order  to  counteract 
this  the  medical  attendant  must  insist  upon  from  fifteen  to 
thirty  minutes  of  absolute  muscular  relaxation,  with  the 
subject  lying  prone  on  the  back  in  a  quiet  darkened  room  until 
sufficient  time  has  elapsed  for  the  creation  of  a  new  feeling  of 
bodily  vigor  not  apparent  at  the  beginning  of  the  exercises 
herewith  illustrated. 

When  the  patient  has  acquired  sufficient  experience  with 
the  resistance  exercises,  as  given  by  an  expert  operator  (espe- 
cially after  returning  to  his  home),  he  can  train  himself  to 
imitate  these   movements   by   a   scheme   of  "self-resistance." 


300      IDISEASES    OF   THE    CARDIOVASCULAR   SYSTEM. 

This  method  requires  the  simultaneous  contraction  of  mus- 
cles that  are  antagonistic  to  each  other.  All  the  rules  pre- 
viously laid  down  for  passive  resistance  movements  must  be 
carefulh^  observed,  or  physical  injury  to  the  myocardium  may 
be  the  result  of  such  neglect. 

The  illustrations  of  the  resistance  exercises  which  follow 
are  self-explanatory,  but  a  descriptive  legend  has  been  ap- 
pended to  each  figure,  thus  presenting  a  detailed  account  of 
the  various  movements  (Figs.  21  to  61  inclusive). 


*  Fig.  21. — Exercise  Xo.  1.  (First  movement.)  The  patient  standing 
erect  extends  both  arms  directly  forward  at  the  shoulder  level,  with 
the  tips  of  his  fingers  touching.  The  operator  places  his  fingers  on  the 
outer  side  of  the  patient's  wrist  and  his  thumb  on  the  patient's  palm. 
The  patient  now  swings  his  arms  outward  in  a  quarter  circle  until 
fully,  extended  at  right  angles.  The  operator  advances  a  step  toward 
the  patient  and  makes  resistance  on  the  outer  aspect  of  both  wrists 
until  the  movement  is  completed. 


*  This  series  of  illustrations,  from  Schott's  Balneogymnastic  Treatment  in 
Chronic  Diseases  of  the  Heart,  are  used  through  the  courtesy  of  P.  Blakiston's 
Son  &  Co.,  Philadelphia,  publishers  of  the  American  edition  of  this  work. 


GYMNASTIC    POSES    FOR    RESISTANCE    EXERCISES.    301 


I'ig.  22. — Exercise  No. 
1.  (Second  movement:) 
The  operator  shifts  his 
iingers  to  th.e  pahnar 
surface  of  the  patient's 
hands  and  again  makes 
resistance  as  the  patient 
returns  his  hands  to  the 
primary  position  in  front. 
The  operator  retreats  a 
step  backward  to  allow 
room  for  the  patient's 
hands  to  come  together. 

— Pause. — 


Fig.  23.-^ExERCiSE  No. 
2.  (First  movement,) 
The  patient  standing, 
with  hands  at  his  side 
and  palms  against  his 
body,  raises  both  hts 
arms  outward  and  up- 
ward to  the  level  of  his 
shoulders.  The  operator 
makes  resistance  by  pres- 
sing on  the  backs  of  the 
patient's  hands  with  the 
palms  of  his  own  hands. 


302       DISEASES    OF   THE    CARDIOVASCULAR    SYSTEM. 


Bt"'"  ■         %fW'^ 


Fig.  24. — Exercise  No. 
2.  (First  movement 
completed.)  The  arms 
of  the  patient  are  now 
fully  extended  and  the 
first  movement  com- 
pleted  to  the  level  of  his 
shoulders,  while  the  op- 
erator still  maintains  his 
I'esi  stance. 


Fig.  25. — Exercise  No. 
2.  (Second  movement.) 
The  operator  changes  his 
resistance  by  placing  his 
palms  beneath  the  ex- 
tended palms  of  the  pa- 
tient, while  the  patient 
returns  his  arms  to  the 
primary  position  at  his 
side. 

— Pause. — 


GYMNASTIC    POSES    FOR    RESISTANCE    EXERCISES.    303 


Fig.  26. — Exercise  No. 
3.  (First  Movement.) 
The  patient  standing 
with  his  arms  at  his  side 
raises  his  hands  forward 
and  upward  to  the  level 
of  his  shoulders.  The 
operator  makes  counter- 
pressure  on  the  upper 
edge  of  the  patient's 
wrists  with  his  thumbs 
but  substitutes  his  fin- 
gers as  the  movement 
nearg  completion. 


Fig.  27. — Exercise  No. 
3.  (First  movement  con- 
tinued.) The  arms  of 
the  patient  are  extended 
in  front  while  passing- 
upward  from  the  hori- 
zontal position  to  a  ver- 
tical position  above  his 
head.  The  operator  con- 
tinues to  make  resistance 
with  his  palms  on  the 
patient's  wrists, 


304      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 


Fig.  28. — Exercise  Xo. 
3.  (First  movement 
completed.)  The  pa- 
tient's arms  have  reached 
a  vertical  position.  The 
operator  is  still  opposing 
this  movement  by  press- 
ing his  palms  on  the 
backs  of  the  patient's 
hands. 


Fig.  29. — Exercise  No. 
3.  (Second  movement.) 
The  patient  now  reverses 
the  movement  and  pres- 
ses downward  returning 
his  arms  to  the  primary 
position  at  his  side.  The 
operator  changes  his  re- 
sistance by  pressing 
against  the  lower  edge 
of  the  patient's  palms  or 
wrists  with  the  tips  of 
his  fingers. 

— Pause. — 


GYMNASTIC    POSES    FOR   RESISTANCE   EXERCISES.   305 


^^^^■•S^H    ^^        ^^^^B^*' 

|PBr^"''.rfV  M"' 

Fig.  30. — Exercise  No. 
4.  ( I'^irst  movement.) 
The  patient  standing 
with  his  arms  held  at  his 
side  presses  backward 
and  upward.  The  opera- 
tor standing  behind  re- 
sists this  movement  by 
pressure  on  the  backs  of 
the  patient's  wrists. 
When  the  limit  of  this 
movement  is  reached  the 
reverse  is  begun  and  re- 
sisted by  the  operator 
who  makes  pressure  on 
the  front  of  the  patient's 
wrists  until  the  primary 
position  is  reached. 

— Pause. — 


Fig.  31.— Exercise  No. 
5.  The  patient  standing 
rotates  his  left  arm. 
The  operator  offers  re- 
sistance by  grasping  the 
patient's  wrist.  The  pa- 
tient duplicates  this  exer- 
cise by  rotating  his  right 
arm  in  the  same  manner. 

— Pause. — 


20 


306      DISEASES    OF    THE    CARDIOVASCULAR   SYSTEM. 


Fig.  Z2. — Exercise  No. 
6.  (First  movement.) 
The  operator  standing 
just  back  of  the  patient 
places  one  .hand  on  the 
patient's  shoulder  and 
the  other  on  his  wrist. 
The  patient  standing 
with  his  arm  at  his  side 
and  his  elbow  fixed 
flexes  his  arm  until  the 
palm  of  his  hand  touches 
his  shoulder. 


Fig.  Z'h. — Exercise  Xo. 
6.  (Second  movement.) 
The  operator  now  offers 
resistance  to  the  back  of 
the  patient's  wrist  as  the 
patient  extends  his  arm 
and  returns  it  to  the  pri- 
marj'  position.  The  pa- 
tient repeats  the  same 
exercise  with  his  other 
arm. 

— Pause. — 


GYMNASTIC    POSES    FOR    RESISTANCE    EXERCISES.    307 


Fig.  34. — Exercise  No. 
7.  (First  movement.) 
The  patient  standing 
with  his  hand  against  his 
side  presses  his  right 
arm  forward  and  upward 
without  bending  the  el- 
bow, gradually  describ- 
ing a  complete  circle  and 
returning  to  the  primary 
position.  The  operator 
places  one  hand  on  the 
patient's  shoulder  and 
makes  resistance  with 
the  other  hand  on  his 
wrist.  He  changes  his 
resistance  as  the  direc- 
tion of  the  force  changes. 


Fig.  35. — Exercise  No. 
7.  (Second  movement.) 
The  patient  is  returning 
his  arm  to  the  primary 
position.  The  operator 
has  shifted  his  resistance 
to  meet  the  changed  con- 
ditions. The  patient  re- 
peats this  exercise  by  de- 
scribing the  same  arc 
with  his  other  arm. 

— Pause, — 


308      DISEASES    OF    THE    CARDIOVASCULAR    SYSTEM. 


Fig.  36. — Exercise  Xo. 
8.  The  operator  grasps 
the  patient's  wrist  loosely 
with  one  hand  and  makes 
counter-pressure  on  the 
back  of  the  patient's 
hand  with  his  other  hand. 
The  patient  extends  his 
hand  by  an  upward 
movement,  and  then 
flexes  by  a  downward 
movement.  The  patient 
repeats  the  same  exercise 
with  his  other  hand. 

— Pause. — 


Fig.  37. — Exercise  Xo. 
9.  (First  movement.) 
The  patient  standing 
with  one  arm  extended 
at  right  angles  and  the 
pahn  of  his  hand  facing 
upward  flexes  his  arm 
until  his  hand  touches 
his  shoulder.  The  oper- 
ator supports  the  upper 
arm  of  the  patient  by 
placing  one  hand  beneath 
it  and  makes  resistance 
by  pressing  on  the  front 
of  the  patient's  wrist 
with  his  other  hand. 


GYMNASTIC    POSES    FOR   RESISTANCE   EXERCISfiS.   309 


Fig.  38. — Exercise  No. 
9.  (Second  movement.) 
The  operator  supports 
the  patient's  elbow  with 
one  hand  and  makes 
counter-pressure  on  the 
back  of  the  patient's 
wrist  with  his  other  hand 
as  the  patient  returns  his 
arm  to  the  primary  posi- 
tion. The  patient  repeats 
the  same  exercise  with 
his  other  arm. 

— Pause. — 


Fig.  39. — Exercise  No. 
10.  (First  movement.) 
The  operator  stands  at 
the  right  side  of  the  pa- 
tient and  with  his  right 
arm  extended  across  the 
patient's  chest  grasps  the 
left  shoulder  with  his 
right  hand,  and  at  the 
same  time  presses  on  the 
small  of  the  patient's 
back  with  his  left  hand. 
The  patient  then  slowly 
bends  the  trunk  forward 
until  a  right  angle  is 
nearly  reached. 


1  ^^^^^B 

k-  <•    -      ■  ■   -:iMjWr 

s'"^ 

wmam 

310      DISEASES    OF   THE    CARDIOVASCULAR   SYSTEM. 


Fig.  40. — Exercise  No. 
10.  (Second  movement.) 
The  operator  changes  his 
right  hand  to  the  front 
of  the  patient's  chest  and 
his  left  hand  to  the  pa- 
tient's back  between  the 
shoulders,  where  he 
makes  counter-pressure 
as  the  patient  straightens 
up  into  the  primarj^  posi- 
tion. 

— Pause. — 


Fig.  41. — Exercise  No. 
11.  (First  movement.) 
The  patient  properly  sup- 
ported by  the  operator's 
hand  on  the  back  of  his 
neck  and  the  other  on  his 
chest,  bends  his  trunk 
backward  as  far  as  pos- 
sible. 


GYMNASTIC   POSES    FOR   RESISTANCE   EXERCISES.    311 


Fig.  42. — Exercise  No. 
11.  (Second  movement.) 
The  operator  presses 
with  his  right  hand  on 
the  patient's  chest  and 
his  left  hand  on  the  small 
of  the  patient's  back  as 
the  patient  returns  to  the 
primary  position. 

— Pause. — 


Fig.  43. — Exercise  No. 
12.  (First  movement.) 
The  patient  bends  the 
trunk  of  his  body  side- 
ways. The  operator 
stands  at  the  front  of 
the  patient  with  his  right 
hand  on  the  patient's 
chest  under  the  left 
axilla  and  his  left  hand 
on  the  patient's  right  hip. 
The  patient  then  bends 
his  body  toward  the  left 
side. 


312      DISEASES   OF   THE   CARDIOVASCULAR   SYSTEM. 


Fig.  44. — Exercise  No. 
12.  (Second  and  third 
movements.)  The  oper- 
ator now  reverses  his 
hands  and  makes  counter- 
pressure  as  the  patient 
bends  his  body  toward 
the  right  side.  The  op- 
erator again  reverses  his 
hands  and  makes  coun- 
ter-pressure as  the  pa- 
tient returns  to  the  pri- 
mary' vertical  position. 

— Pause. — 


Fig.  45. — Exercise  Xo. 
13.  (First  movement.) 
The  operator  standing  in 
front  places  both  hands 
on  both  shoulders  of  the 
patient.  The  patient  then 
rotates  his  trunk  to  the 
extreme  right  side,  while 
the  o/j  ^ra^or  presses 
against  the  left  shoulder 
and  pulls  on  -the  right 
shoulder,  meanwhile  step- 
ping halfway  around  the 
patient. 


GYMNASTIC   POSES   FOR   RESISTANCE   EXERCISES.   313 


Fig.  46. — Exercise  No. 
13.  (Second  and  third 
movements.)  The  same 
movement  is  repeated  by 
the  patient  turning  to- 
ward the  left  side,  the 
operator  pulling  on  the 
left  shoulder  and  press- 
ing on  the  right.  The 
patient  again  reverses 
and  returns  to  the  pri- 
mary position,  while  the 
operator  makes  a  reverse 
counter-pressure  and 
steps  back  to  his  first 
station. 

— Pause. — 


Fig.  47. — Exercise  No. 
14.  (First  movement.) 
The  patient  standing 
rests  one  hand  on  the 
back  of  the  chair  while 
the  operator  stooping- 
places  right  hand  on  the 
front  of  the  patient's 
ankle  and  resists  the  for- 
ward position  of  the  pa- 
tient's foot. 


uB^^^^S^,  ^• 

314      DISEASES    OF   THE    CARDIOVASCULAR   SYSTEM. 


Fig.  48. — Exercise  No. 
14.  (Second  movement.) 
The  operator  reverses  his 
hand  to  behind  the  pa- 
tient's ankle  while  the 
patient  draws  his  foot 
backward  to  the  primarj- 
position.  The  same  ex- 
ercise is  repeated  with 
the  patient's  other  foot. 

— Pause. — 


Fig.  49. — Exercise  No. 
15.  (First  movement.) 
The  patient  standing 
rests  one  hand  on  the 
back  of  the  chair  and  ex- 
tends his  foot  laterally, 
outward  and  upward, 
while  the  operator  stoop- 
ing makes  resistance  on 
the  outer  side  of  the  pa- 
tient's ankle. 


GYMiNASTJC    POSES    FOR    RESISTANCE    EXERCISES.   315 


Fig.  50. — Exercise  No. 
15.  (Second  movement.) 
The  patient  returns  his 
foot  to  the  primary  posi- 
tion on  the  floor  while 
the  operator  presses  on 
the  inner  side  of  the  pa- 
tient's ankle.  The  same 
exercise  is  duplicated 
with  the  patient's  other 
foot. 

— Pause. — 


Fig.  51. — Exercise  No. 
16.  (First  movement.) 
The  patient  standing 
with  both  hands  resting 
on  the  back  of  the  chair 
presses  his  leg  backward 
and  upward  while  the  op- 
erator stooping  makes 
counter-pressure  on  the 
back  of  the  patient's 
ankle. 


'■''           111- 

^. 

ii4rsl^HP^ 

V     jik 

0^ 

K^-i 

H^^^^l 

Ir  *•■,.  i 

316      DISEASES   OF   THE   CARDIOVASCULAR   SYSTEM. 


Fig.  52. — Exercise  No. 
16.  (Second  movement.) 
The  operator  changes  his 
resistance  to  the  front  of 
the  patient's  ankle,  as  the 
patient  returns  his  foot 
to  the  primary  position. 
The  same  exercise  is  du- 
plicated with  the  patient's 
other  foot. 

— Pause. — 


Fig.  53. — Exercise  No. 
17.  (First  movement.) 
The  operator  stooping 
makes  pressure  on  the 
top  of  the  patient's  foot 
while  the  patient  stand- 
ing rests  one  hand  on  the 
back  of  the  chair  and 
draws  his  foot  directly 
upward. 


j 

^ 

GYMNASTIC   POSES    FOR    RESISTANCE   EXERCISES.   31/ 


Fig.  54. — Exercise  No. 
17.  (Second  movement.) 
The  operator  reverses 
his  resistance  by  placing 
his  hand  beneath  the  sole 
of  the  patient's  foot  as 
the  patient  returns  his 
foot  to  the  primary  posi- 
tion. The  same  exercise 
is  duplicated  with  the  pa- 
tient's other  foot. 

— Pause. — 


Fig.  55. — Exercise  No. 
18.  The  patient  standing 
rests  one  hand  on  the 
back  of  the  chair  and  ro- 
tates his  leg  to  the  right 
and  left  virhile  the  opera- 
tor stooping  grasps  the 
patient's  leg  near  the 
ankle.  The  patient  re- 
peats the  same  exercise 
with  his  other  foot. 

— Pause. — 


318      DISEASES   OF   THE   CARDIOVASCULAR   SYSTEM. 


Ik''^' 

. 

1       ^  .       i  w 

^^    >1 

'^"-  ^" 

^Wr 

Fig.  56. — Exercise  No. 
19.  (First  movement.) 
The  patient  seated  in  a 
chair  presses  one  foot 
forward  while  the  opera- 
tor stooping  makes  re- 
sistance with  his  hand  on 
the  front  of  the  patient's 
ankle. 


Fig.  57. — Exercise  No. 
19.  (Second  movement.) 
The  operator  makes 
counter-pressure  at  the 
back  of  the  patient's 
ankle  as  the  patient  re- 
turns his  foot  to  the  pri- 
mary position.  The  pa- 
tient repeats-  the  same 
exercise  w-ith  his  other 
foot. 

— Pause. — 


GYMNASTIC   POSES   FOR   RESISTANCE   EXERCISES.  319 


- 

c 

^\ 

J^5,     ■ 

L^ 

~,  it 

m 

5^^^^ 

'■■■^^^^"^  nm 

1' 

^KKS^os^^^^^ 

Fig.  58. — Exercise  No. 
20.  (First  movement.) 
The  patient  seated  in  a 
chair  presses  his  knees 
outward  as  the  operator 
stooping  makes  counter- 
pressure  with  his  hands 
on  the  outer  side  of  each 
knee. 


Fig.  59. — Exercise  No. 
20.  (Second  movement.) 
The  operator  changes  his 
resistance  to  the  inner 
side  of  each  knee  as  the 
patient  returns  his  knees 
to  the  primary  position. 

— Pause. — 


320      DISEASES    OF   THE   CARDIOVASCULAR   SYSTEM. 


Fig.  60. — Exercise  No. 
21.  (First  movement.) 
The  patient  seated  flexes 
his  foot  as  the  operator 
stooping  makes  counter- 
pressure  on  the  top  of 
the  patient's  foot. 


Fig.  61. — Exercise  No. 
21.  (Second  movement.) 
The  operator  changes  his 
resistance  to  the  sole  of 
the  patient's  foot  as  the 
patient  returns  his  foot 
to  the  primary  position. 
The  patient  repeats  the 
same  exercise  writh  his 
other  foot. 

— Pause. — 


BIBLIOGRAPHY.  321 


BIBLIOGRAPHY. 

1.  Amer.  Jour.  Med.  Sciences,  June,  1915. 

2.  Bliss :      Rontgen    Diagnosis    in    Pathologic    Lesions   of    the   Teeth, 
Penna.  Jour,  of  Rontgenology,  January,  1917,  p.  9. 

3.  Lewis :     Mechanism  of  the  Heartbeat,  p.  266. 

4.  Arch.  d.  mal.  du  coeur,  Feb.,  1916. 

5.  Am.  Jour.  Med.  Sciences,  July,  1915. 

6.  Kuno :     Journal  of  Physiology,  1915,  p.  2. 

7.  Starling:     Lancet,  i,  569. 

8.  Robey:     Amer.  Jour.  Med.  Science,  cliii,  No.  4,  546. 

9.  From  Carter's  Diet  Lists,  Saunders,  Phila.,  1914. 

10.  Zentralblatt  fiir  Physiologic,  No.  20. 

11.  Prager  medizinische  Wochenschrift,  No.  43,  p.  601. 

12.  Physiological  Chemistry,  Lecture  XX. 

13.  Warthin:  Am.  Jour.  Med.  Sciences,  October,  1916,  No.  535,  p.  508; 
also  Transactions  of  the  Association  of  the  American  Physicians,  1914, 
p.  416. 

14.  Howard :     Johns  Hopkins  Bulletin,  iii,  266. 

15.  Irving:    Jour.  A.  M.  A.,  Ixiv,  No.  13,  935. 

16.  Cohn :     Jour.  Exper.  Med.,  xxi,  No.  6. 

17.  Jour.  Pharm.  and  Exp.  Then,  iii,  89. 

18.  Jour.  A.  M.  A.,  Ixiv,  898. 

19.  Hall :     Medical  Times,  xliv,  39. 

20.  Amer.  Jour.  Med.  Sciences,  cxlix,  696. 

21.  Jour.  Pharm.  and  Exp.  Ther.,  vi.  331. 

22.  Schott :  Balneogymnastic  Treatment  in  Chronic  Diseases  of  the 
Heart.    English  Trans,  by  S.  Lewis  Ziegler,  M.D.,  Phila,  1914. 

23.  Ibid. 

24.  Schott:     Berliner  klinische  Wochenschrift,  1885. 


21 


Diseases  of  the  Respiratory  System 


FRANK  A.  CRAIG,  M.D., 

Instructor  in  Medicine,  University  of  Pennsylvania;  Visiting  Physician, 
Henry  Pliipps  Institute,  University  of  Pennsylvania;  Visiting  Phy- 
sician, White  Haven  Sanatorium;  Physician  in  Charge  of  the  Tuber- 
culosis Class,  Presbyterian  Hospital,  Philadelphia. 


(323) 


Diseases  of  the  Respiratory  System. 


FOREWORD. 

The  importance  of  the  diseases  of  the  lungs  may  be  readily 
determined  by  a  study  of  the  mortality  reports  published  by 
any  large  community,  where  it  will  be  seen  that  the  deaths 
due  to  diseases  of  the  respiratory  system,  including^pulmonary 
tuberculosis,  far  exceed  those  due  to  diseases  of  any  other  system. 

In  spite  of  the  enormous  annual  loss  from  these  dis- 
eases, they  have  not  received  the  attention  that  their  impor- 
tance would  warrant — with  the  possible  exception  of  pulmon- 
ary tuberculosis.  Even  here  the  greatest  progress  has  been 
along  lines  of  prevention  and  the  development  of  a  more  effi- 
cient method  of  applying  remedial  measures,  rather  than  any 
distinct  improvement  in  the  actual  diagnosis  or  treatment  of 
the  disease  in  the  individual  case.  The  increased  interest  in 
these  diseases  manifested  in  more  recent  years  is  probably 
to  be  accounted  for  by  the  fact  that  the  Rontgen  rays  offered 
a  newer  method  of  study,  and  the  diseases  of  the  lungs  have 
been  more  and  more  the  subject  of  surgical  treatment,  which 
necessarily  requires  a  very  great  accuracy  in  diagnosis.  The 
Wassermann  reaction  and  the  salvarsan  preparations  have 
undoubtedly  also  stimulated  interest  in  the  pulmonary  mani- 
festation of  syphilis,  and  recent  studies  of  the  chronic  non- 
tuberculous  diseases  of  the  lungs  have  opened  a  new  field  of 
investigation. 

The  following  pages  do  UQt  contain  any  very  radical 
changes  in  the  methods  employed  for  various  diseases  of  the 
respiratory  system.  The  effort  has  been  made  to  present  a 
brief  review  of  the  pathologic  anatomy,  diagnosis,  and  treat- 
ment of  the  more  common  conditions,  avoiding  as  much  as 
possible  the  various  opinions  held  by  dififerent  writers,  and 
confining  the  work  as  much  as  possible  to  the  views  most  gen- 
erally accepted  among  the  observers  whose  experience   and 

(325) 


326  DISEASES    OF    THE    RESPlI^\TORY    SYSTEM. 

judgment  would  appear  to  make  them  best  qualified  to  decide 
such  questions.  The  sections  on  diagnosis  and  treatment  are 
not  intended  to  cover  the  entire  field,  but  to  describe  such 
methods  as  have  proved  of  practical  value  in  recognizing-  dis- 
ease, and  the  lines  of  treatment  which  have  given  the  best 
results  in  my  personal  experience.  Where  I  have  felt  that  my 
experience  was  not  sufficiently  extensive  to  w^arrant  the  draw- 
ing of  conclusions,  the  views  of  more  experienced  men  have 
been  accepted. 

The  work  is  written  in  the  hope  that  it  will  present  to  the 
practising  physician  a  study  of  the  various  diseases  of  the 
respirator}-  system  which  will  prove  of  help  in  the  handling 
of  these  conditions,  which  are  so  prevalent,  and  frequently  so 
resistant  to  treatment. 

ACUTE    AND    SUBACUTE    BRONCHITIS. 

The  treatment  of  this  extremel}'-  common  aft'ection  may  be 
considered  under  several  different  headings  as  proph3dactic, 
local,  or  general,  the  plan  pursued  in  the  individual  case  being- 
dependent  upon  whether  the  condition  is  primary  or  second- 
ary, and  the  portion  of  the  bronchial  system  aft'ected.  A 
knowledge  of  the  various  causative  factors  and  a  general  con- 
ception of  the  pathologic  processes  involved  are  essential  for 
an  intelligent  management  of  the  case. 

The  disease  may  be  briefly  described  as  a  catarrhal  process 
of  the  mucosa  of  the  larger  bronchi,  the  smaller  bronchi,  and 
the  bronchioles,  either  alone  or  in  various  combinations.  In 
the  earl}^  stages  it  is  characterized  by  a  hyperemia  of  the  mem- 
brane, which  becomes  reddened,  swollen,  and  congested.  In 
this  stage  the  surface  is  usually  covered  with  a  small  amount 
of  mucopurulent  secretion  of  a  very  tenacious  character. 
With  the  development  of  the  second  stag^e  the  h3'peremia 
diminishes,  with  an  increase  in  the  amount  of  secretion,  which 
at  first  may  be  thick  and  tenacious,  but  later  becomes  more 
copious  and  less  viscid,  as  the  exudation  from  the  blood-ves- 
sels and  the  secretion  from  the  mucous  glands  become  freer. 
With  the  progress  of  the  disease  the  expectoration  tends  to 
lose  its  mucoid  character  and.become  more  purulent.  ]\Iicro- 
scopically,  the  condition  is  characterized  by  an  engorgement 


ACUTE   AND    SUBACUTE    likONCillTlS.  327 

of  the  smaller  blood-vessels  and  capillaries,  a  leucocytic  infil- 
tration, and  relaxation  and  swelling  of  the  inner  tibrous  coat. 
The  basement  membrane  becomes  edematous  and  wrinkled, 
and  a  separation  of  the  ciliated  columnar  epithelium  occurs. 
The  lumen  of  the  smaller  bronchi,  which  have  Ijecome  dimin- 
ished by  the  hyperemia,  may  be  partly  occluded  by  the  des- 
quamated cells,  leucocytes,  and  the  secretion  of  the  mucous 
glands.  As  the  process  becomes  more  severe  the  leucocytic 
infiltration  may  invade  the  deeper  portions  of  the  bronchial 
walls,  as  well  as  the  muscular  and  outer  fibrous  coats.  The 
secretion  from  the  mucous  glands  becomes  progressively  ex- 
cessive as  the  process  develops,  a  process  of  desquamation 
usually  affecting  the  epithelial  and  secretory  elements  of  the 
glands. 

The  onset  of  the  disease  is  usually  sudden,  with  a  feeling  of 
chilliness,  malaise,  general  pains,  headache,  and  a  sensation  of 
rawness  or  tickling  in  the  trachea.  As  the  acute  catarrhal 
process  is  seldom  confined  to  the  bronchial  mucous  membrane, 
the  signs  of  coryza,.  pharyngitis,  or  laryngitis  are  usually  as- 
sociated with  the  symptoms  of  bronchitis. 

The  signs  and  symptoms  of  bronchitis  correspond  to  what 
one  would  expect  as  a  result  of  the  pathologic  processes  in  the 
bronchi.  During  the  early  stages  the  cough  is  hard,  dry, 
unproductive,  with  substernal  soreness  and  pain,  a  sense  of 
suffocation  or  embarrassed  breathing,  and  on  examination 
sonorous  or  sibilant  rales  are  found,  when  the  smaller  bronchi 
or  bronchioles  are  affected.  When  the  trachea  and  main 
bronchi  only  are  inflamed,  if  the  process  is  not  of  a  severe  type, 
physical  signs  may  be  entirely  lacking  on  examination  of  the 
chest.  As  the  second  stage  develops,  the  difficulty  in  breathing 
and  pain  may  disappear  as  the  secretion  is  coughed  up  with 
greater  ease,  the  cough  is  not  so  incessant,  and  on  examination 
the  character  of  the  rales  becomes  more  indicative  of  moisture. 

The  chief  cause  of  primary  bronchitis  is  bacterial  invasion, 
but  even  here  there  is  usually  some  secondary  factor  which  is 
indirectly  responsible  for  the  infection,  such  as  irritation  of 
the  mucous  membrane  by  various  dusts,  chemical  irritants, 
noxious  gases,  smoke,  and  atmospheric  conditions.  There 
may  be  some  lowering  of  the  general  resistance  of  the  individ- 
ual, such  as  follows  sudden  chilling,  prolonged  exposure  to 


328  DISEASES    OF    THE   RESPIRATORY    SYSTEM. 

cold  and  moisture,  alcoholic  excesses,  and  general  diseases,  or 
it  may  be  merely  an  extension  of  a  similar  process  in  the 
upper  air  passages,  such  as  cor}^za,  tonsillitis,  pharyngitis, 
laryngitis,  and  similar  conditions.  As  a  secondary  process 
bronchitis  accompanies  many  of  the  general  infections,  such 
as  the  acute  contagious  diseases  common  to  childhood,  influ- 
enza, typhoid  fever,  malaria,  tuberculosis,  and  syphilis,  and  is 
commonly  met  with  in  persons  suffering  from  various  chronic 
diseases,  such  as  cardiac  aft'ections,  nephritis,  gout,  rheuma- 
tism, and  the  acute  and  chronic  non-tuberculous  diseases  of 
the  lungs. 

In  the  majority  of  cases  the  micro-organisms  directly 
responsible  for  the  bronchitis  are  the  influenza  bacillus,  the 
pneumococcus,  streptococci,  staphylococci,  micrococcus  catar- 
rhalis,  either  singly  or  in  various  .combinations.  Less  fre- 
quently other  pyogenic  bacteria  have  been  found  in  the  sputum 
in  bronchitis,  but  the  possibility  of  contamination  of  the 
sputum  with  germs  from  the  mouth,  in  spite  of  careful  wash- 
ing and  other  measures  to  prevent  such  a  source  of  error, 
makes  one  hesitate  to  accept  many  of  the  published  reports 
upon  the  bacteriolog}-  of  acute  bronchitis.  The  micro-organ- 
isms mentioned  are  frequently  responsible  for  the  acute  bron- 
chitis accompanying  the  infectious  diseases,  such  as  typhoid 
fever  and  tuberculosis,  although  the  bacteria  causing  the  sys- 
temic infection  may  be  the  direct  cause  of  the  bronchial  inflam- 
mation. 

TREATMENT. 

The  first  step  in  the  management  of  a  case  of  acute  bron- 
chitis consists  in  the  determination  of  any  possible  secondary 
cause,  and  its  correction  by  appropriate  treatment.  The  elim- 
ination of  various  occupational  dusts,  improvement  of  the  gen- 
eral resistance  to  infections  by  the  correction  of  errors  in  living 
conditions  and  change  of  climate,  the  improvement  of  various 
functions  of  the  body  impaired  on  account  of  functional  or 
organic  disease,  all  are  important  measures,  especially  from  the 
standpoint  of  prevention. 

Upon  the  first  indication  of  the  disease  it  may  be  possible 
to  abort  the  attack  by  appropriate  measures,  such  as  absolute 
rest  in  bed  (an  extremely  important  measure),  hot  lemonade 


Acute  and  subacute  bronchitis.  329 

or  similar  hot  drinks,  either  with  or  without  whisky,  hot  mus- 
tard foot-bath,  and  thorough  eHmination  through  the  skin,  kid- 
neys, and  intestinal  tract.  In  this  stage  there  is  probably  no 
medicine  quite  so  valuable  as  Dover's  powder  in  doses  of  3 
grains  (0.19  Gm.),  repeated  hourly  for  three  doses. 

The  general  pains  and  malaise  may  be  so  severe  as  to 
demand  special  treatment,  and  there  is  probably  no  better 
method  of  relieving  these  symptoms  than  by  the  use  of 
phenacetin  in  3-grain  (0.19  Gm.)  to  5-grain  (0.32  Gm.)  doses 
every  two  or  three  hours.  Aspirin  may  be  used  instead  of 
the  phenacetin,  or  combined  with  it,  in  doses  of  3  to  5  grains 
(0.19  to  0.32  Gm.).  The  profuse  sweating  which  occasionally 
follows  the  use  of  aspirin  is  not  a  disadvantage,  but  certain 
individuals  have  an  idiosyncrasy  toward  this  drug  which  may 
be  manifested  by  generalized  edema,  chiefly  of  the  face,  ears, 
and  neck.  The  saline  purgatives  are  especially  indicated  in 
adults,  while  castor  oil  is  more  satisfactory  in  children.  To 
derive  any  benefit  from  increased  intestinal  elimination,  it  is 
necessary  to  secure  active  purgation,  with  copious,  watery 
evacuations,  and  this  should  be  borne  in  mind  in  prescribing 
the  purgatives,  so  that  the  dose  may  be  sufficiently  large  to 
insure  obtaining  the  desired  results.  Laxatives  or  purgatives 
in  insufficient  doses  only  add  to  the  discomfort  of  the  patient 
without  any  benefit  being  derived  from  their  administration. 
The  local  application  of  heat  to  the  chest  not  only  relieves 
the  sense  of  tightness  and  soreness,  but  seems  to  aid  in  re- 
lieving  the  congestion  of  the  bronchial  mucous  membranes, 
promoting  secretion  and  quieting  cough.  This  is  especially 
true  in  young-  children,  in  whom  local  measures  alone  will 
often  serve  to  relieve  completely  all  symptoms  of  bronchial 
irritation  or  inflammation,  The  local  applications  most  com- 
monly employed  are  mustard  plasters,  poultices,  kaolin,  and 
turpentine  stupes  (the  fumes  from  which  may  prove  irritat- 
ing), or  rubbing  the  chest  with  camphorated  oil  or  camphor 
liniment  may  give  more  comfort  and  relief.  The  mustard  plas- 
ters prepared  by  the  commercial  houses  have  the  advantage 
of  being  light  in  weight,  cleanly,  easily  applied,  and  may  be 
moved  readily  from  one  part  of  the  chest  to  another.  Unless 
the  home-made  mustard  plaster  is  carefully  prepared,  it  may 
only  add  another  discomfort  to  the  patient.     Many  patients 


S3G  DISEASES    OF   tHE   RESPIRATORY   SySTEM. 

derive  considerable  relief  from  rubbing  the  chest  with  liniment 
containing-  oil  of  gaultheria. 

When  the  large  bronchi  are  chiefly  affected,  relief  may  be 
obtained  from  the  inhalation  of  a  spray  of  bland  oil  to  which 
has  been  added  small  quantities  of  menthol,  eucalyptol,  cam- 
phor, or  creosote,  the  finely  divided  spray  being  directed 
toward  the  posterior  pharynx,  while  the  patient  takes  deep 
inhalations  which  are  retained  as  long  as  possible.  The  in- 
halation of  steam  is  also  of  considerable  help,  especially  when 
impregnated  with  compound  tincture  of  benzoin,  sodium  chlo- 
rid,  sodium  carbonate.,  creosote,  or  chloroform.  While  the 
various  appliances  for  inhaling  steam  are  very  convenient,  the 
use  of  a  preserving-jar  one-third  full  of  boiling  water  to  which 
is  added  the  medication  desired,  serves  the  purpose  very  well, 
especially  if  surrounded  by  a  towel  which  makes  it  more  con- 
venient for  handling  and  also  helps  to  direct  the  steam  by 
fitting  closely  around  the  patient's  mouth.'  The  use  of  steam  is 
of  special  value  in  young  children,  especially  when  the  smaller 
bronchi  are  affected,  when  it  may  be  found  more  convenient  to 
use  the  croup-kettle  and  tent  on  account  of  the  difflculty  in 
having  them  use  the  inhaler.  The  use  of  the  hot  pack  is  also 
of  considerable  help  in  these  young  patients,  particularly  when 
the  attack  is  severe  and  accompanied  by  considerable  difficulty 
in  breathing. 

It  is  also  necessary  to  pay  attention  to  the  general  sur- 
roundings of  the  patient ;  to  see  that  rest  in  bed  is  persisted  in ; 
to  provide  a  sufficient  supply  of  warm,  fresh  air;  and  to 
secure  free  elimination  by  the  bowels,  kidneys,  and  skin. 
While  a  light,  easily  digested  diet  is  desirable,  care  must  be 
taken  to  see  that  the  patient  receives  sufffcient  nourishment, 
as  it  is  of  the  greatest  importance  to  have  the  general  nutri- 
tion maintained. 

In  the  early  stages  the  drug  which  is  of  special  value  is 
potassium  citrate,  given  in  doses  of  5  to  15  grains  (0.32  to 
0.97  Gm.)  every  hour  or  two  to  be  of  any  value,  to  which  may 
be  added  spiritus  setheris  nitrosi  in  doses  of  15  to  30  minims 
(0.97  to  1.94  mil).  The  increased  elimination  by  the  kidneys, 
skin,  and  intestines  will  usually  be  sufficient  to  relieve  the 
bronchial  congestion.  When  the  cough  is  very  "tight,"  with 
scanty,  tenacious  expectoration,  it  may  be  necessary  to  give, 


ACUTE  AND  SUBACUTE  BRONCHITIS.      -331 

in  addition  to  the  above,  syrup  of  ipecac  5  to  15  minims  (0.32 
to  0.97  mil),  or  syruip  of  squill  15  to  30  minims  (0.97  to  1.94 
mil).  Apomorphin  in  doses  of  %2  to  ^/24  of  a  grain  (0.002 
to  0.0027  Gm.)  may  prove  useful  in  some  cases  for  increasing 
the  amount  of  secretion  from  the  bronchi,  and  rendering  it 
easier  to  expectorate. 

All  emetics  should  be  given  in  small  doses,  gradually  in- 
creased, as  many  individuals  are  extremely  susceptible  to 
them,  even  small  doses  causing  very  distressing  nausea,  and 
perhaps  vomiting.  While  antimony  and  aconite  are  used  quite 
frequently  in  this  stage,  they  should  be  used  with  extreme 
caution,  on  account  of  the  possibility  of  their  causing  exces- 
sive depression. 

It  is  in  the  ear.ly  stage  that  opium  or  its  derivatives  are 
occasionally  of  value  in  controlling  the  incessant,  hard,  unpro- 
ductive cough,  but  owing  to  the  general  tendency  to  employ 
opiates,  especially  heroin  and  codein,  too  freely  in  bronchitis, 
even  in  cases  in  which  they  are  contraindicated,  a  word  of 
caution  might  not  be  out  of  place.  In  the  very  young  or  the 
ag'ed  any  opiate  should  be  employed  with  extreme  care,  and 
never  in  cases  in  which  there  is  much  difhculty  in  breath- 
ing, or  where  the  bronchioles  are  inflamed  to  any  great  extent; 
opiates  are  always  contraindicated  in  the  cases  in  which  there 
is  considerable  secretion  to  be  expelled.  The  field  of  useful- 
ness of  opiates  in  bronchitis  is  confined  to  those  cases  in  which 
the  cough  is  excessive  and  out  of  all  proportion  to  the  amount 
of  expectoration,  and  even  here  it  may  be  questionable  as  to 
whether  the  comfort  obtained  from  their  use  is  not  counter- 
balanced by  their  tendency  to  check  secretion,  the  stimulation 
of  which  is  one  of  the  objects  of  the  treatment  in  this  stage. 
When  the  danger  of  exhaustion  from  the  constant,  hard  cough 
becomes  imminent,  and  it  is  necessary  to  obtain  some  relief  for 
the  patient,  it  will  be  found  that  Dover's  powders  in  small 
doses  frequently  repeated  will  be  much,  more  advantageous 
than  either  heroin,  codein,  or  morphin.  While  Dover's  pow- 
der only  contains  10  per  cent,  of  ipecac,  one  must  be  care- 
ful in  prescribing  an  additional  quantity  of  ipecac  to  avoid 
giving  this  drug  in  excess  of  the  expectorant  dose. 

For  increasing  the  quantity  of  the  secretion  and  render- 
ing it  less  tenacious,  there  is  probably  no  drug'  which  is  of  so 


332  •       DISEASES   OF   THE  RESPIRATORY   SYSTEM. 

much  value  as  ammonium  chlorid  in  5-grain  doses  (0.32  Gm.) 
every  two  or  three  hours.  While  certain  vehicles  commonly 
employed  are  soothing  to  the  pharynx,  it  is  inadvisable  to 
administer  expectorants  in  syrups,  especially  w^hen  given  at 
frequent  intervals,  or  over  a  prolonged  period ;  peppermint 
water,  cinnamon  water,  or  some  similar  solvent  will  be  found 
much  more  satisfactor}^  in  the  average  case. 

When  there  is  a  copious  tenacious  secretion  in  the  smaller 
bronchi  and  bronchioles,  it  may  become  imperative  at  times, 
especially  in  children,  to  secure  active  evacuation  of  the  col- 
lected secretions,  on  account  of  the  obstruction  to  breathing. 
Ipecac  or  apomorphin  in  emetic  doses  will  usually  bring  about 
the  desired  result,  the  mucus  being  mechanically  dislodged  by 
the  violent  efforts  of  vomiting.  It  may  be  necessary  to  resort 
to  the  more  stimulating  expectorants,  if  the  secretions  should 
continue  for  any  prolonged  period.  (See  p.  336.)  Occasion- 
ally the  cough  and  expectoration  are  of  a  spasmodic  character, 
in  which  case  belladonna,  stramonium  and  lobelia  may  prove 
of  value;  or  the  expectoration  may  be  very  copious,  when, 
again,  belladonna  may  be  employed.  At  times  the  attack  of 
bronchitis  is  accompanied  by  signs  of  prostration  and  cardiac 
weakness,  especially  in  elderly  people  or  those  exhausted  by 
prolonged  illness,  in  which  event  prompt  stimulation  may  be 
necessary.  Many  cases  of  acute  bronchitis  do  not  completely 
recover  from  the  acute  attack,  and  are  left  with  a  slight  occas- 
ional cough,  with  more  or  less  expectoration.  Most  of  these 
are  more  benefited  by  tonic  treatment  and  by  insistence  upon 
a  rational  mode  of  life  than  by  any  treatment  directed  toward 
the  bronchial  mucosa. 

CHRONIC    BRONCHITIS. 

An  acute  attack  of  bronchitis  may  be  prolonged  for  a  period 
of  time  so  as  to  warrant  the  term  "chronic  bronchitis"  being 
employed,  and  under  this  heading  are  included  the  cases  of 
frequently  recurring-  attacks  of  acute  bronchitis.  Bronchitis 
of  a  chronic  type  extending  over  a  long  period  is  very 
rare  as  a  primary  disease,  and  its  occurrence  should  at  once 
suggest  that  there  is  some  secondary  condition  responsible  for 
the  persistence  of  the  cough,  especially  when  present  in  young 


CHRONIC    BRONCHITIS.  333 

people.  Continued  exposure  to  irritating-  dusts  and  fumes 
may  occasionally  be  responsible,  but  tuberculosis,  chronic  dis- 
ease of  the  heart,  chronic  non-tuberculous  disease  of  the  lungs, 
nephritis,  gout,  and  other  diseases  should  always  be  suspected 
in  these  cases,  and  when  present  receive  appropriate  treat- 
ment. Recurrent  "winter  coughs"  are  not  uncommon,  appear- 
ing each  year  with  the  first  damp,  cold  days  of  autumn,  and 
continuing  through  the  winter;  these  occur  frequently  in 
elderly,  debilitated  people,  but  may  also  occasionally  affect 
the  young-. 

In  chronic  bronchitis  the  changes  found  in  the  acute  form 
are  usually  present  in  a  modified  form.  The  mucous  mem- 
brane of  the  bronchi  appears  reddened,  thickened,  and  ulcer- 
ated, or  may  be  entirely  lacking,  the  denuded  surface  of  the 
muscular  and  fibrous  layers  being  exposed.  Microscopically, 
the  leucocytic  infiltration  may  invade  the  entire  bronchial 
wall,  even  extending  into  the  peribronchial  tissues.  Connec- 
tive tissue  may  replace  the  cellular  exudate,  and  atrophy  of  the 
tissue  of  the  bronchial  walls  and  desquamation  of  the  epi- 
thelium is  a  not  uncommon  result.  The  mucous  follicles  may 
undergo  ulceration,  and  there  may  be  slight  dilatation  of  the 
bronchi  which  have  lost  their  elasticity. 

TREATMENT. 

The  most  important  step  in  the  treatment  is  to  make  sure 
that  it  is  not  secondary  to  disease  in  some  other  part  of  the 
body,  and  the  next  to  make  sure  that  there  is  no  obstruction 
present  to  prevent  the  patient  breathing  through  the  nose. 
Nothing  could  be  more  conducive  to  frequent  infection  of  the 
bronchial  mucosa  than  being  constantly  exposed  to  the  cold, 
dry,  unfiltered  air  which  results  from  mouth-breathing.  The 
air  should  pass  through  the  nose  in  order  that  it  become 
warmed,  moistened,  and  clea^ned,  a  function  which  the  internal 
nasal  chambers  are  so  well  fitted  to  perform.  Possible  sources 
of  infection  should  also  be  sought  for,  such  as  chronic  sinus 
disease,  tonsillar  abscesses,  and  mouth  infections. 

The  measures  which  promise  the  greatest  benefit  are  those 
directed  toward  the  general  health  of  the  patient,  and  while 
a  change  of  climate  is  frequently  of  value,  this  it  is  not  always 
possible  to  secure. 


334  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Treatment  should  be  directed  toward  the  relief  of  any  dis- 
ease which  might  have  any  bearing  upon  the  bronchitis,  as  one 
could  not  expect  much  from  medication  for  the  relief  of  the 
bronchial  symptoms  so  long  as  the  causative  factor  persists. 

Where  there  is  evidence  of  cardiac  weakness  or  valvular 
incompetence,  it  is  necessary  to  apply  such  measures  as  will 
help  to  overcome  the  difficulty,  depending  upon  the  nature  of 
the  cardiac  disease.  For  these  cases  rest,  digitalis,  atropin, 
and  massage  ma}-  be  employed,  according  to  the  etiolog}-  and 
amount  of  the  decompensation. 

Where  nephritis  exists,  such  dietary  changes  as  may  be 
required  should  be  instituted,  together  with  such  restrictions 
in  the  amount  of  salt  or  fluids  ingested  as  may  seem  necessary 
from  a  study  of  the  functional  capacity  of  the  kidneys.  The 
bronchitis  accompanying  pulmonary  tuberculosis  is  considered 
in  detail  in  the  section  dealing  with  that  disease.     (See  p.  446. ) 

The  measures  followed  by  the  greatest  benefit  are  those 
directed  toward  the  improvement  of  the  general  health  of 
the  patient,  and  no  detail  of  the  patient's  mode  of  life  is 
too  insignificant  to  receive  the  careful  attention  of  the  physi- 
cian in  charge,  if  he  expects  to  make  any  headway  in  the 
treatment  of  this  disease,  A  study  of  the  patient's  customary 
dietary  should  be  undertaken,  and  such  changes  made  as  may 
be  indicated.  The  clothing  of  the  patient  should  be  warm 
enough  for  comfort,  but  not  so  heavy  as  to  induce  a  constant 
state  of  perspiration,  most  people  finding  the  open  mesh  under- 
wear more  satisfactory  than  the  woolen  for  this  reason.  It  is 
much  wiser  to  depend  upon  the  outer  clothing  for  warmth,  as 
they  are  more  easily  changed  to  meet  the  requirements.  In 
the  wanter-time  warm  or  fairly  hot  baths  may  be  employed, 
preferably  just  before  retiring,  or  if  taken  during  the  daytime 
they  should  always  be  followed  by  a  cool  or  cold  sponge  bath 
and  thorough  rubbing  down  with  a  rough  towel.  Sufficient 
fresh  air  should  be  obtained  both  day  and  night,  and  on  wet, 
raw,  or  windy  days  if  possible  the  patient  should  avoid  going 
out,  but  if  not  possible  should  be  thoroughly  protected  against 
the  cold  and  moisture.  Windy  days  are  especially  objection- 
able on  account  of  the  dust  in  the  air.  The  living-  and  sleep- 
ing- rooms  should  be  well  ventilated,  which  does  not  neces- 
sarily mean  that  they  must  be  cold,  as  it  is  possible  to  obtain  a 


CHRONIC    BRONCHITIS.  335 

constant  supply  of  warm  fresh  air.  When  steam  or  hot-water 
heat  is  employed,  it  is  especially  necessary  to  see  that  fresh 
air  is  admitted  to  the  room,  and  the  intense  dryness  of  the  air 
from  these  systems  of  heating  may  be  largely  overcome  by 
keeping  large  open  vessels  of  water  on  the  radiators.  The 
bedclothing  should  be  sufficient  to  keep  the  patient  com- 
fortably warm,  but  excessive  coverings  should  be  avoided. 
The  discomfort  resulting  from  the  excessive  weight  of  many 
bedcovers  may  be  avoided  in  most  cases  by  placing  extra 
covers  between  the  mattresses  or  beneath  the  lower  sheet. 
Sleeping  between  blankets  or  sheets  made  of  outing  flannel 
may  prove  advantageous  in  very  cold  weather  to  those  who 
suffer  from  cold  extremities,  or  when  patients  prefer  sleeping 
in  a  cold  room  or  outdoors. 

When  the  patient's  financial  resources  permit,  great  relief 
during  the  winter  months  may  be  obtained  by  a  sojourn  in 
some  of  the  southern  resorts.  It  is  impossible  to  lay  down 
any  fixed  rules  as  to  which  patients  will  be  benefited  by  a 
stay  at  the  seashore,  inland,  mountains,  etc.,  as  each  case 
seems  to  be  a  law  unto  itself,  the  special  climate  which  seems 
to  be  best  suited  to  the  patient  being  determined  by  experience 
or  experiment.  Where  there  are  secondary  factors  involved, 
the  question  of  climate  may  be  largely  influenced  by  the 
nature  of  the  secondary  process. 

The  general  tonics  such  as  iron,  quinin,  strychnin,  arsenic, 
and  similar  drugs  are  of  considerable  value  in  many  cases, 
giving  relief  from  the  annoying  symptoms  of  chronic  bron- 
chitis in  many  instances  in  which  measures  more  espe- 
cially directed  toward  the  bronchitis  have  proved  useless. 
Cod-liver  oil  is  of  value  in  many  cases,  even  in  the  absence  of 
coincident  pulmonary  tuberculosis.  Considerable  relief  may 
be  obtained  from  the  inhalations  and  local  measures  suggested 
for  the  treatment  of  acute  bronchitis.  The  cough  is  likely  to 
be  extremely  annoying  in  the  morning,  for  the  mucus  which 
has  collected  during  the  nig"ht  usually  requires  considerable 
effort  to  dislodge.  On  rising  in  the  morning  a  glass  of  hot 
water  to  which  has  been  added  10  grains  (0.648  Cm.)  of 
sodium  bicarbonate,  5  grains  (0.32  Gm.)  of  sodium  chlorid 
will  frequently  relieve  the  morning  cough,  permitting  the 
secretions  to  be  expectorated  more  easily.     The  efficacy  of 


336  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

this  mixture  may  be  increased  in  some  cases  by  the  addition 
of  10  to  15  minims  (0.64  to  0.97  mil)  of  spirit  of  chloroform. 

For  the  rehef  of  the  cough  and  expectoration  in  chronic 
bronchitis,  terpin  hydrate  is  probably  one  of  the  best  drugs 
which  we  possess,  but  it  must  be  given  in  full  doses  to  obtain 
the  desired  effect.  Terpin  hydrate  may  be  given  in  capsules 
containing  3  to  5  grains  (0.19  to  0.32  Gm.)  each  three  or  four 
times  daily,  preferably  after  meals.  The  elixir  of  terpin 
hydrate  is  a  ver}^  convenient  form  in  which  the  drug  may  be 
prescribed,  as  it  contains  2  grains  (0.13  Gm.)  of  terpin 
hydrate  to  the  dram,  and  it  may  be  given  in  doses  of  1  or  2 
teaspoonfuls  (4  or  8  mils)  or  even  3  teaspoonfuls  (12  mils),  if 
necessary.  As  it  contains  a  high  percentage  of  alcohol,  it 
must  be  freely  diluted  with  water,  the  powdered  drug  being 
preferable  in  any  case  in  which  the  use  of  alcohol  is  contra- 
indicated.  Creosote  (see  section  on  Tuberculosis)  is  also  of 
a  great  deal  of  value,  especially  where  the  expectoration  is 
purulent  or  fetid.  When  the  mucus  is  tenacious  and  scanty, 
potassium  or  ammonium  iodid  in  doses  of  5  to  10  grains 
(0.32  to  0.64  Gm.),  will  aid  considerably  in  rendering  the 
mucus  more  copious,  and  relieving  the  cough.  Other  drugs 
which  have  been  recommended  in  chronic  bronchitis  are  oil 
of  cloves,  oil  of  sandalwood,  oil  of  eucalyptus,  oil  of  turpen- 
tine, oil  of  copaiba,  balsam  of  Peru,  balsam  of  tolu,  terebene, 
tar,  and  a  number  of  similar  drugs.  The  great  disadvantage 
which  practically  all  of  these  stimulating  expectorants  possess 
is  their  tendency  to  cause  derangement  of  the  stomach  if  con- 
tinued for  any  length  of  time;  for. this  reason  ammonium 
chlorid,  terpin  hydrate,  and  creosote  are  the  drugs  upon 
which  the  main  reliance  will  have  to  be  placed  in  the  treatment 
of  this  chronic  process. 

As  a  prophylactic  and  remedial  agent  in  both  acute  and 
chronic  bronchitis,  bacterial  vaccines  have  been  administered 
in  many  cases  during  recent  years  with  varying  success.  The 
main  objection  to  this  method  of  treatment  lies  in  the  diffi- 
culties attending  the  determination  of  the  micro-organisms 
responsible  for  the  infective  process  in  any  given  cas«.  In 
spite  of  the  various  measures  suggested  for  collecting  and 
washing  the  sputum,  it  is  impossible  to  tell  which  bacteria 
are  actually  causing  the  inflammation  of  the  bronchial  mucosa, 


FIBRINOUS    BRONCHITIS.  337 

even  were  it  possible  to  eliminate  absolutely  the  possibility  of 
contamination  of  the  expectoration  by  mouth  bacteria.  The 
preparation  of  an  autogenous  vaccine  is  a  very  unsatisfactory 
procedure,  as  it  is  impossible  to  tell  whether  the  important 
micro-org'anism  in  a  given  case  has  been  included  in  the  vac- 
cine or  not,  and  stock  commercial  vaccines  are  open  to  the 
same  objections  in  a  more  marked  degree.  It  is,  therefore,  not 
to  be  wondered  at  that  the  results  obtained  by  vaccine  therapy 
should  vary  so  greatly,  and  it  makes  it  much  more  difficult  to 
determine  the  actual  value  of  such  a  method  of  treatment. 

In  a  patient  who  is  subject  to  repeated  attacks  of  acute  or 
chronic  bronchitis,  where  other  methods  of  treatment  have 
proven  unavailing,  it  may  be  worth  while  trying  to  secure  a 
bacterial  vaccine  prepared  from  bacteria  recovered  from  his 
own  sputum,  especially  when  the  washed  sputum  has  repeat- 
edly shown,  in  predominant  numbers,  the  presence  of  certain 
micro-organisms  of  recognized  pathogenicity.  While  our 
present  knowledge  indicates  that  the  injection  of  these  bac- 
terial vaccines  are  unaccompanied  by  any  harmful  effects,  it 
would  seem  wiser  not  to  use  them  indiscriminately  in  the 
absence  of  special  indications,  until  further  investigation  has 
shown  whether  they  are  absolutely  without  danger  or  not. 

FIBRINOUS    BRONCHITIS. 

This  relatively  rare  form  of  bronchitis  may  occur  as  a  pri- 
mary disease,  but  it  is  more  frequently  met  with  as  a  second- 
ary process  in  some  disease  of  the  lungs  or  bronchi.  Cases 
have  been  observed  in  patients  suffering  from  pulmonary 
tuberculosis,  asthma,  pneumonia,  diphtheria,  typhoid  fever, 
measles,  scarlet  fever,  actinomycosis,  chronic  passive  conges- 
tion, and  as  a  result  of  the  inhalation  of  steam,  ammonia 
fumes,  and  smoke.  The  fact  that  the  condition  occurs  in  the 
course  of  so  many  different  diseases  would  make  it  appear  as 
if  the  predisposing  cause  was  not  peculiar  to  any  special  mor- 
bid process,  and  that  the  fibrinous  bronchitis  was  merely 
incidental  in  its  occurrence  and  not  an  integral  part  of  the 
associated  disease. 

Fibrinous  bronchitis  is  characterized  by  the  formation 
within  the  lumen. of  the  bronchial  tubes  of  casts  composed  of 

22 


338  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

fibrin  and  mucin  in  varying-  proportions.  The  casts  develop 
in  dilterent  parts  of  the  bronchial  tree,  and  are  expectorated 
from  time  to  time  after  violent  paroxysmal  attacks  of  cough- 
ing-. The  disease  may  occur  in  an  acute  form  with  the  forma- 
tion of  large  casts  occupying  a  considerable  portion  of  the  bron- 
chial system,  in  which  case  severe  dyspnea,  relieved  only  by 
the  coughing  up  of  the  large  fibrinous  casts,  may  accompany 
the  attack. 

The  pathology  of  the  process  is  obscure,  and  while  at  one 
time  the  view  was  held  that  denudation  of  the  bronchial 
mucosa  was  essential  for  the  fibrinous  exudate  to  collect  in 
the  bronchi,  it  has  been  shown  that  casts  may  form  in  bronchi 
whose  mucosa  is  intact.  The  nature  of  the  process  and  the 
local  conditions  necessary  to  permit  or  to  cause  this  exudation 
of  fibrin  through  the  mucosa  of  certain  portions  of  the  bron- 
chial system  is  absolutely  unknown.  While  bacteria  have 
been  supposed  to  pla}-  a  prominent  role  in  the  process,  this 
relationship  has  never  been  proved,  and  all  efforts  to  produce 
the  condition  experimentally  by  the  intra-bronchial  injection 
of- bacteria  have  so  far  been  unsuccessful. 

The  symptoms  of  the  acute  and  chronic  cases,  consisting 
of  cough,  dyspnea,  and  the  expectoration  of  casts,  are  prac- 
tically the  same,  although  they  differ  markedly  in  severity. 
In  the  acute  form  the  cast  is  usually  larger  than  in  the  chronic 
type,  the  dyspnea  and  cough  are  prone  to  be  much  more  severe, 
and  may  last  for  one  or  two  days  before  the  cast  is  expec- 
torated. While  cases  have  been  reported  which  terminated 
fatally  from  asphyxia  due  to  occlusion  of  the  bronchi  by  large 
casts,  this  accident  is  extremely  rare.  The  chronic  forms  are 
not  so  severe  as  the  acute,  and  not  attended  with  such  severe 
cough  or  dyspnea.  The  casts  may  be  so  small  that  there  may 
be  no  dyspnea,  and  the  expectoration  of  the  small  plugs  may 
not  be  accompanied  by  an  unusually  severe  cough.  The  casts 
may  be  expectorated  at  intervals  of  varying  length  over  a  con- 
siderable period  of  time. 

The  physical  signs  var\"  with  the  size  of  the  cast  and  its 
location.  When  large  casts  lodge,  there  may  be  restricted 
movement  of  one  side  of  the  chest,  and  the  signs  of  bronchial 
obstruction  are  present  over  the  area  of  the  lung  supplied  by 
the  obstructed  bronchi.    Dullness  may  be  present,  but  usually 


BRONCHIECTASIS.  339 

percussion  is  negative,  and  there  are  diminished  or  absent 
breath-sounds  over  the  area  affected,  the  breath-sounds  return- 
ing- after  the  cast  has  been  expelled.  Sonorous  rales,  usually 
localized,  may  be  present,  and  a  peculiar  flapping  sound  has 
been  described  as  occurring  in  certain  cases  due  to  the  par- 
tial detachment  of  the  bronchial  cast. 

The  casts  vary  from  small  white  masses,  only  recognizable 
as  of  bronchial  origin  when  floated  in  water,  to  large,  branched 
masses  with  the  typical  bronchial  arrangement,  several  inches 
in  length.  They  are  white  or  grayish-white  in  color,  and  on 
section  it  may  be  seen  that  the  thicker  branches  show  a  con- 
centric laminated  arrangement. 

TREATMENT. 

The  treatment  of  the  attack  consists  of  attempting  to  aid 
in  the  freeing  of  the  cast  and  its  expulsion  by  means  of  sprays 
of  lime-water  and  steam  inhalations.  Apomorphin  hydro- 
chlorate  hypodermically  has  been  suggested  to  assist  in  expel- 
ling the  cast.  The  only  drug  which  seems  to  be  of  any  value 
internally  in  the  treatment  of  the  chronic  cases  is  the  iodide  of 
potassium  in  large  doses,  and  instances  have  been  reported 
in  which  the  administration  of  the  drug  has  been  followed  by 
complete  recovery.  In  those  cases  in  which  the  dyspnea  is 
severe  the  signs  of  impending  suffocation  may  necessitate  an 
attempt  to  remove  the  cast  by  bronchoscopy  as  a  means  of 
preventing  a  fatal  termination. 

When  the  process  accompanies  some  other  disease,  this 
naturally  should  receive  active  treatment,  and  the  usual  meas- 
ures for  ordinary  bronchitis  should  be  employed,  for  the  process 
is  almost  invariably  accompanied  by  evidence  of  a  general  bron- 
chial catarrh. 

BRONCHIECTASIS. 

Dilatation  of  the  bronchi  is  a  condition  which  varies  very 
much  in  its  general  characteristics  and  etiology  in  different 
cases.  While  it  may  occur  rarely  as  a  primary  disease,  usually 
it  is  secondary  to  some  other  process,  the  generalized  bron- 
chiolectasis  of  childhood  coming  nearer  to  what  may  be 
classed  as  a  primary  disease  than  any  other  type,  although 


340  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

even  here  usualh-  there  is  a  histor}-  of  preceding  bronchitis. 
The  causes  may  be  briefly  stated  as:  (1)  changes  in  the  bron- 
chi themselves,  such  as  loss  of  tone  in  the  walls,  stenosis,  or 
obstruction  of  the  bronchus ;  (2)  changes  in  the  lung,  such  as 
collapse,  pneumonia,  fibrosis,  or  emph^^sema;  (3)  changes  in 
the  pleura,  such  as  compression  of  the  lung  due  to  eitusion 
of  long  standing,  or  the  extension  into  the  lung  of  a 
fibrosis  originating  in  the  pleura.  Thus  bronchiectasis  may 
result  from  acute  bronchitis,  tuberculosis,  syphilis,  foreign 
bodies,  new  growths,  aneurisms,  pulmonar}-  cirrhosis  or 
fibrosis,  lobar,  or  broncho-pneumonia,  chronic  pneumonia, 
pleurisy,  or  empyema.  When  it  accompanies  tuberculosis  it 
mav  aft'ect  the  bronchi  of  the  upper  portion  of  the  lung, 
although  the  lower  lobes  are  the  parts  usually  implicated. 
Onh-  rarely  is  the  course  of  one  bronchus  implicated,  the  pro- 
cess usuallv  being  multiple  or  dift'use. 

The  bronchiectasis  may  occur  as  a  uniform  cylindrical 
dilatation  of  the  bronchi,  aft'ecting  the  larger  branches  only, 
or  extending  to  the  smaller  ramifications.  Certain  portions  of 
the  lung  or  lungs  ma}-  share  in  the  process,  the  remaining 
bronchi  showing  no  abnormality,  or  one  entire  lung  ma}-  be 
aft'ected,  but  only  very  rarely  does  the  process  implicate  both 
lungs  in  a  generalized  uniform  dilatation  of  the  entire  bron- 
chial system.  The  dilatation  is  uniformly^  cylindrical  in  only 
an  extremely  small  proportion  of  the  cases,  nearly  every  case 
presenting  constrictions  of  the  bronchi  here  and  there  through- 
out their  course.  The  saccular  or  globular  type  may  occur  in 
association  with  the  above,  or  as  a  single  process.  In  this 
form  certain  areas  of  the  lung,  which  may  be  of  considerable 
extent,  are  occupied  by  numerous  small,  rounded  saccules 
varying  in  size,  and  usually  found  to  communicate  with  the 
bronchi.  The  lung  tissue  in  these  cases  usually  is  very  much 
diminished;  or  may  have  completely  disappeared,  being  re- 
placed by  fibrous  tissue  of  varying  density. 

Microscopically,  the  changes  are  similar  to  those  found  in 
acute  or  chronic  bronchitis,  depending  upon  the  stage  of  the 
disease,  the  process  as  a  rule  being  more  intense  and  extensive 
than  in  bronchitis.  Thus,  in  bronchiectasis  it  is  customary  to 
find  the  connective  tissue  proliferation  invading  the  entire 
bronchial  wall  and  surrounding  tissue,  with  compression  and 


ekONCHIECTASIS.  341 

atrophy  of  the  normal  muscular  and  fibrous  tissues  of  the 
Ijronchus.  In  some  instances  all  semblance  to  bronchial  wall 
is  destroyed,  the  tube  being  surrounded  by  a  thick  mural  par- 
tition of  dense  connective  tissue. 

The  exact  nature  of  the  pathologic  process  underlying  the 
production  of  bronchiectasis  is  still  an  unsettled  question,  but 
whether  due  to  factors  within  the  bronchi,  such  as  increased 
pressure,  or  to  conditions  in  the  surrounding  tissues,  such  as 
traction  and  localized  compression  from  contracting  connec- 
tive tissue  arising  in  the  lung  or  pleura,  it  must  be  conceded 
that^an  affection  of  the  bronchial  walls  themselves  is  the 
essential  factor.  This  change  in  the  bronchial  walls  in  many 
cases  appears  to  be  the  principal  cause  of  the  lesion,  and  in 
some  cases  it  may  be  the  only  one  detectable.  The  exact 
nature  and  mode  of  operation  of  this  process  is  not  very  well 
understood. 

From  the  standpoint  of  diagnosis  the  symptoms  usually 
are  more  characteristic  than  the  physical  signs,  and  the  diag- 
nosis may  at  times  be  made  upon  the  symptoms  alone. 
Among  the  most  important  subjective  signs  is  the  type  of 
cough  and  expectoration  so  common  in  these  cases,  namely, 
fairly  long  periods  during  which  there  may  be  slight  cough,  or 
none  at  all,  terminating  in  acute  attacks  of  cough,  with  the 
expectoration  of  mucopurulent,  frequently  offensive  material 
which  varies  in  amount,  but  is  commonly  excessive.  This 
accumulation  and  putrefaction  of  the  bronchial  secretion  over 
long  periods!  of  time  indicatesi  in  the  majority  of  cases  a  dilata- 
tion of  the  bronchi,  the  material  only  being  expectorated  when 
the  cavity  has  become  overfilled  or  when  some  change  of  posi- 
tion has  caused  it  to  flow  into  the  adjacent  bronchi.  The 
periods  between  the  attacks  may  vary  from  a  few  hours  to 
several  days,  or  even  longer,  depending  upon  circumstances. 
At  times  this  evacuation  of  the  bronchial  cavity  is  accom- 
panied by  a  sudden  violent  expulsive  effort,  large  quantities 
of  foul-smelling  pus  being  forcibly  expelled  from  the  patient's 
mouth  or  even  from  the  nose.  The  sputum  is  usuall}^  muco- 
purulent, but  may  consist  of  pus  only,  and  at  times  may  show 
a  tendency  to  .separate  into  three  layers,  as  described  under 
Pulmonary  Abscess  {q-v.).  It  may  be  odorless,  but  is  usually 
stale  or  musty,  and  may  be  exceedingly  foul,  the  odor  being 


342  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

also  given  off  by  the  breath.  In  one  patient  under  the  care 
of  the  writer  the  odor  of  the  breath  was  so  exceedingly  foul 
and  nauseating  as  to  make  it  necessary  to  isolate  the  individual 
from  the  other  patients  in  the  sanatorium. 

Hemorrhages,  usually  small  in  amount,  may  occur,  and  are 
due  to  vascular  outgrowths  or  small  ulcers  on  the  bronchial 
walls,  but  large  and  even  fatal  hemorrhages  have  been  re- 
ported as  a  result  of  rupture  of  branches  of  the  pulmonary 
artery  by  erosion  of  the  bronchial  wall.  The  other  symptoms 
which   may   be   present   are   those    referable   to   the    general 


Fig.  1. — Pulmonary  osteo-arthropathy.  Thickening  of  the  distal 
phalanges  and  curving  of  the  nails  in  long-standing  bron- 
chiectasis. 

toxemia  resulting  from  the  accumulation  of  pus,  or  to  the 
bronchial,  pulmonary,  or  pleural  conditions  responsible  for 
the  bronchiectasis. 

The  physical  signs  are  to  a  great  extent  influenced  by  the 
associated  disease  process,  as  bronchiectasis  is  infrequent  in 
a  primary  form.  During'  the  early  stages  the  general  health 
of  the  subject  may  not  be  affected,  and  there  may  be  no  ele- 
vation of  temperature  as  long  as  the  cavity  is  frequently 
evacuated.  Hypertrophic  pulmonary  osteo-arthropathy  is 
more  frequently  present  in  bronchiectasis  than  in  any  other 
pulmonary  disease,  and  the  clubbing  of  the  fingers  and  toes 
may  be  extreme.  The  drumstick  appearance  of  the  fingers, 
due  to  the  enlargement  of  the  distal  phalanx,  may  be  the  only 


BRONCHIECTy\SIS.  343 

evidence  of  the  disease,  or  all  of  the  phalanges  may  be  clubbed, 
and  even  the  distal  extremities  of  the  bones  of  the  wrist  and 
ankles,  the  chang'es  being  due  to  hypertrophy  of  the  perios- 
teum and  the  formation  of  new^  bone. 

The  examination  of  the  chest  in  uncomplicated  cases  may 
reveal  signs  of  a  cavity  w^hen  the  contents  of  the  dilated 
bronchi  have  been  expelled,  or  there  may  be  only  scattered 
areas  of  impairment  on  percussion  and  localized  rales.  These 
may  be  bubbling,  with  a  metallic,  resonant  quality,  or  merely 
tine,  moist,  and  crepitant,  due  to  the  secondary  changes  in  the 
surrounding  pulmonary,  tissue.  The  signs  of  cavity  may  be 
elicited  by  placing  the  patient  in  'the  horizontal  decubitusi,  or 
in  the  Trendelenberg  position.  When  the  process  is  deep- 
sieated  there  may  be  no  physical  signs  evident  on  the  exami- 
nation of  the  chest,  even  in  cases  in  which  all  the  symptoms 
and  general  appearance  of  the  patient  indicate  that  dilatation 
of  the  bronchi  is  present.  As  previously  stated,  the  associated 
changes  in  the  pleura  or  lungs  may  be  of  such  a  character  as 
to  obscure  the  signs  of  dilated  bronchi  on  examination  of  the 
chest. 

The  x-vdcy  examination  may  be  employed  with  advantage 
in  some  cases,  especially  when  the  physical  signs  are  obscure. 
The  changes  in  the  shadows  observed  in  plates  taken  before 
and  after  the  evacuation  of  the  accumulated  fluid  is  extremely 
suggestive  in  some  cases. 

Anyone  who  has  seen  these  distressing  cases  in  the  ad- 
vanced stages,  in  which  the  odor  of  the  breath  is  so  foul  and 
nauseating  that  they  cannot  associate  with  anyone,  expectorat- 
ing large  quantities  of  foul-smelling  pus  at  frequent  intervals, 
cannot  help  but  be  impressed  with  the  futility  of  our  present 
methods  of  treating  this  condition. 

TREATMENT. 

The  most  important  step  is  the  improvement  in  the 
patient's  general  condition  by  means  of  tonics,  nourishing 
food,  rest,  and  fresh  air,  as  outlined  under  Tuberculosis.  An 
effort  should  be  made  to  correct  any  chronic  bronchitis  that 
may  be  present  by  means  of  creosote,  terpine  hydrate,  oil  of 
sandalwood,  oil  of  cloves,  and  similar  stimulating  expector- 
ants.    The  direct  application  of  healing,  antiseptic  substances 


344  DISEASES    OF   THE   RESPIR-\TORY   SYSTEM. 

has  been  attempted  by  means  of  inhalations  and  intratracheal 
injections,  with  the  object  of  rendering  the  expectoration  less 
purulent,  and  overcoming  putrefactive  changes  in  the  accumu- 
lated material  in  the  bronchi.  The  fumes  of  turpentine  may 
be  employed  by  placing  a  teaspoonful  (4  mils)  of  the  oil  in  a 
pint  (500  mils)  of  boiling  water,  an  improvised  inhaler  for 
which  ma}-  be  made  by  means  of  a  quart  jar  surrounded  by  a 
towel.  Creosote,  oil  of  eucalyptus,  carbolic  acid,  and  thymol 
may  be  used  in  a  similar  manner.  Various  drug's  may  be  em- 
ployed in  the  form  of  a  spray,  or  the  fumes  inhaled  when  they 
are  volatile,  and  for  the  latter  a  mask  may  be  employed  upon 
which  are  placed  such  drugs  as  are  indicated.  The  mask  for 
providing-  medicated  inhalations  has  never  proved  very  pop- 
ular in  this  country,  the  discomfort  of  wearing  such  an  ap- 
pliance being  hardly  compensated  by  the  results  obtained. 
The  mask  is  only  suitable  for  use  during  the  daytime  when  the 
patient  is  confined  to  the  house,  or  in  a  sanatorium  or  hos- 
pital, although  there  is  no  objection  to  its  being  worn  at  night, 
when  a  certain  amount  of  benefit  may  be  obtained  in  the 
few  hours  during  which  it  is  worn.  A  popular  formula  for  a 
mixture  to  be  employed  in  this  manner  is  equal  parts  of  car- 
bolic acid  or  thymol,  rectified  spirits,  and  glycerin,  10  drops 
(0.6  mil)  of  the  preparation  being  dropped  upon  the  face  mask 
and  renewed  as  required. 

A  method  of  treatment  very  strongly  recommended  con- 
sists in  placing  the  patient  in  a  closed  room  in  which  creosote 
is  heated  in  a  metal  saucer  by  means  of  a  spirit-lamp.  It  is 
necessary  first  to  protect  the  patient's  hair  and  clothing  by 
suitable  impervious  coverings,  to  plug-  the  ears  and  nose  Avith 
cotton,  and  to  wear  goggles  over  the  eyes.  The  dense  fumes 
of  the  creosote  quicklv  fill  the  room,  the  patient  being  exposed 
to  them  for  about  fifteen  minutes  on  alternate  days  at  first, 
then  every  day,  the  time  of  exposure  graduall)-  being  pro- 
longed as  the  patient  becomes  accustomed  to  the  fumes — 
even  up  to  an  hour  and  a  half  twice  daily.  The  effect  at  first 
is  to  start  up  a  severe  cough,  with  a  marked  increase  in  the 
amount  of  expectoration,  but  the  severity  of  the  cough  dimin- 
ishes as  the  patient  grows  hardened  to  the  treatment.  While 
strongly  recommended  in  this  condition,  it  must  indeed  be  a 
persevering  patient  who  would  continue  such  an  unpleasant 


BRONCHIECTASIS.  345 

method  of  treatment,  unless  marked  improvement  followed  the 
ordeal  very  soon  after  it  v^as  instituted.  The  modification  of 
the  above  may  be  used  by  floating  the  creosote  on  v^ater  in  a 
small  pan  under  which  the  burner  is  placed,  thus  afifording 
steam  creosote  inhalations  instead  of  the  pure  fumes  obtained 
by  the  other  method.  The  steam  inhalations  are  borne  very 
much  better  by  the  majority  of  patients. 

The  direct  application  of  remedial  agents  to  the  bronchi 
has  been  carried  out  by  means  of  intratracheal  injections. 
These  are  made  by  means  of  a  syringe  with  a  Jong,  curved 
nozzle,  and  cause  the  patient  very  little  discomfort,  if  care  is 
exercised  in  making  the  injection  to  have  the  tip  of  the  nozzle 
well  beyond  the  larynx,  and  the  amount  injected  does  not 
exceed  1  dram  (4  mils).  The  fluid  injected  may  be  directed 
toward  either  lung  by  having  the  patient  lie  upon  the  cor- 
responding side  after  the  injection  is  made.  The  drugs  are 
usually  combined  with  olive  oil  as  a  vehicle,  and  the  mixture 
warmed  before  use.  Menthol,  iodoform,  eucalyptol,  creosote, 
guaiacol,  and  silver  and  iodin  compounds  have  been  em- 
ployed in  this  manner.  A  formula  which  has  been  recom- 
mended consists  of  menthol  10  parts,  guaiacol  2  parts,  and 
olive  oil  88  parts.  Theoretically  one  should  expect  to  derive 
a  great  deal  of  benefit  from  this  form  of  treatment ;  that  the 
results  obtained  are  not  as  satisfactory  as  one  would  antici- 
pate may  be  inferred  from  the  fact  that  this  method  of  treat- 
ment has  not  been  more  generally  adopted. 

Bacterial  vaccines  have  been  recommended  in  the  treat- 
ment of  this  condition,  and  with  encouraging  results  in  some 
cases.  The  objection  to  this  plan  of  treatment  is  the  same  as 
in  the  case  of  bronchitis,  but  to  a  greater  extent.  The  pus 
expectorated  from  these  cases  is  very  foul,  and  contains 
numerous  varieties  of  micro-organisms,  many  of  which  can 
have  no  relation  to  the  disease  from  the  standpoint  of  etiology, 
being  merely  secondary  contaminations. 

Where  the  condition  is  due  to  actual  primary  changes  in 
the  bronchial  walls,  to  fibrosis  of  the  lungs,  or  to  the  pressure 
of  new  growths  and  aneurisms,  very  little  can  be  done  in  the 
way  of  radical  treatment.  The  best  that  can  be  expected  in 
such  cases  is  the  amelioration  of  symptoms,  even  those  due  to 
syphilis,  tuberculosis,  and  foreign  bodies  in  the  bronchi,  in 


346 


DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


which  there  is  a  possibility  of  removing  or  curing  the  causa- 
tive factor,  if  the  gross  changes  in  the  bronchi  are  very 
marked  or  extensive,  the  possibility  of  curing  the  condition  by 
medicinal  measures  is  exceedingly  remote. 


Fig.  2a.— Posture :   The  use  of  the  foot  of  the  bed. 


Considerable  comfort  may  be  given  these  patients  by 
relieving  the  cough  and  expectoration,  and  this  can  be  accom- 
plished by  teaching  them  to  assume  for  a  short  period  several 
times  a  day  the  postures  which  facilitate  expectoration.  Thus  a 
patient  with  dilated  bronchi  in  the  lower  lobes  may  secure 
a  very  comfortable  day  if  made  to  lie  for  from  fifteen  to  thirty 


BRONCHIECTASIS.  347 

minutes  every  morning  with  the  feet  much  higher  than  the 
head,  a  position  easily  obtained  by  the  elevation  of  the  foot  of 
the  bed.  He  should  lie  flat  on  the  back,  face,  or  on  either 
side,  depending  upon  which  position  seems  to  facilitate   the 


Fig.  2b. — Posture:    Inverted  position,  use  of  chair.     (Kindness  of 
Dr.  A.  H.  Garvin,  Dr.  H.  W.  Lyall  and  M.  Morita.) 

evacuation  of  the  accumulated  expectoration.  This  same  pro- 
cedure carried  out  at  night  will  usually  secure  a  comfortable 
night's  rest.  The  object  is  to  promote  drainage  from  the 
bronchiectatic  cavities,  thereby  preventing  the  accumulation 
of  pus,  and  the  unfavorable  chain  of  symptoms  resulting  from 


348  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

the  absorption  of  its  products.  A  little  experimentation  will 
soon  decide  the  posture  which  seems  to  promote  this  evacua- 
tion most  readily;  it  may  even  be  necessary  for  the  patient 
completely  to  invert  the  body — a  position  which  can  be 
assumed  by  flexing  the  body  at  the  waist  over  the  foot  of  the 
bed  or  the  back  of  a  chair,  with  the  extended  hands  resting  on  the 
floor.  (Figs.  2a  and  2b.)  Where  feasible,  an  operating  table 
may  be  employed  to  place  the  patient  in  the  Trendelenberg  posi- 
tion, the  subject  lying  either  on  the  face  or  back  as  indicated. 
While  most  cases  derive  considerable  benefit  from  this  postural 
treatment  when  performed  two  or  three  times  a  day,  in  some 
it  will  be  necessary  to  have  them  carry  out  the  procedure  every 
hour  or  two.  The  inverted  position  should  be  maintained  for 
at  least  fifteen  minutes  on  each  occasion,  or  until  complete 
evacuation  has  been  secured,  or  the  discomfort  attending  such 
a  position  proves  too  severe.  This  method  is  especially  suited 
to  those  cases  in  which  the  bronchiectasis  affects  the  bronchi 
below  the  level  of  the  root  of  the  lung,  inasmuch  as  when  the 
cavities  are  above  this  point  the  possibility  of  constant  drain- 
age is  naturally  much  greater.  The  postural  treatment  of  bron- 
chiectasis has  been  followed  in  some  cases  by  striking  results, 
and  should  be  tried  carefully  and  conscientiously  in  every  case. 
That  it  can  be  carried  out  by  the  patient  himself,  is  without 
danger,  and  is  easily  secured  by  anyone,  are  recommenda- 
tions in  its  favor. 

Artificial  pneumothorax  has  been  recommended  in  the 
treatment  of  certain  cases  where  the  pleura  is  not  markedly 
adherent,  and  in  which  the  gross  changes  in  the  lungs  are  not 
extensive  or  very  dense.  Within  recent  years  some  of  these 
cases  in  which  the  lesion  is  limited  and  localized  to  one  lower 
lobe,  surgical  interference  has  been  sug-gested,  with  the 
amputation  of  the  diseased  portion  of  the  lung,  or  subperios- 
teal resection  of  the  ribs.  The  field  of  pulmonary  diseases  has 
so  recently  been  invaded  by  the  surgeons  that  it  would  prob- 
ably be  the  better  plan  not  to  recommend  this  method  of 
treatment  at  the  present  time.  In  the  future  more  care  in  the 
selection  of  cases  and  further  operative  experience  may  pro- 
vide a  surgical  treatment  which  may  prove  of  value  in  treat- 
ing what  at  present  must  be  looked  upon  as  an  almost  hope- 
less condition. 


nRONCHlAL    ASTHMA.  349 

Finally,  when  persistent  treatment  has  failed,  as  it  so  fre- 
quently will  in  this  disease,  it  may  be  adv-isable  to  advise  a 
change  of  climate,  that  last  resort  of  the  discouraged  and  per- 
plexed physician. 

BRONCHIAL    ASTHMA. 

The  older  writers  on  this  subject  described  under  the  name 
asthma  many  varied  conditions,  leading  to  a  certain  amount  of 
confusion,  which  is  still  apparemt  at  times  in  modern  literature. 
Formerly  it  was  the  custom  to  apply  the  name  asthma  to  any 
condition  which  was  accompanied  by  spasmodic  attacks  of  dysp- 
nea, which  was  usually  qualified  by  the  addition  of  the  name  of 
the  associated  condition,  giving  rise  to  such  terms  as  cardiac 
asthma,  renal  astlmia,  etc.  For  many  years  there  was  considera- 
ble discussion  as  toi  whether  there  was  such  a  disease  as  asthma 
which  could  occur  as  a  primary  disease,  or  whether  the  condition 
was  merely  a  symptom  of  some  other  process.  While  the  exact 
nature  »oi  the  process  is  still  somewhat  obscure,  it  is  generally 
recognized  that  bronchial  asthma  may  exist  as  an  essential  disease 
process.,  and  that  while  spasmodic  attacks  of  dyspnea  may  occur 
in  the  course  of  certain  diseases,  which  closely  simulate  bronchial 
asthma,  they  are  not  identical  conditions. 

The  symptoms  are  due  to  a  swelling  and  hypersecretion  of  the 
mucous  membrane  o>f  the  bronchi,  with  possibly  a  certain  amount 
of  spasmodic,  muscular  contraction.  Whether  this  may  come 
about  through  nervous  derangement  alone,  or  whether  it  is  always 
a  manifestation  of  anaphylaxis,  is  still  open  to  question.  The 
more  recent  view  ithat  asthmatic  attacks  are  an  indication  O'f 
intoxication  by  certain  substances  to'  which  the  asthmatic  individ- 
ual has  become  sensitized  is  the  most  plausible  which  has  been 
suggested,  even  if  the  exact  modus  operandi  is  still  uncertain,  and 
some  of  the  cases  strongly  suggest  a  nei*vous  origin.  There  are 
no  clear-cut  or  charaoteristio  gross  pathologic  findings  in  asthma, 
the  few  cases  which  have  come  to  autopsy  during  an  attack  show- 
ing merely  a  redness  of  the  bronchial  mucosa,  with  slight  dilata- 
tion of  the  bronchi,  and  more  or  less  emphysema.  The  medium 
and  smaller  bronchi  are  usually  filled  with  mucus,  which  contains 
epithelial  cells,  granular  material,  leucocytes,  and  the  various 
special  features  described  under  the  sputum.  The  microscopic 
changes  in  the  bronchi  are  in  no  way  characteristic,  with  the  pos- 


350  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

sible  exception  of  the  findings  of  eosinophiles  and  Charcot-Leyden 
crystals  in  the  bronchial  walls,  and  occasionally  an  increase  in  the 
amount  of  elastic  tissue. 

When  present,  the  symptoms  preceding  the  attack  vary  greatly 
in  character,  some  patients  feeling  unusually  well,  others  being 
depressed,  and  many  presenting  the  signs  indicative  of  a  "cold," 
with  general  catarrhal  symptoms.  Occasionally  the  individual 
may  be  warned  of  the  oncoming  attack  by  the  appearance  of  pecu- 
liar prodromal  symptoms,  such  as  voiding  large  quantities  of 
urine,  epigastric  distress,  or  sweating.  The  attacks  usually  come 
on  very  suddenly,  frequently  within  a  few  hours  after  going  to 
sleep,  and  begin  with  a  hard,  dry  cough,  and  difficulty  in  breathing, 
which  becomes  more  and  more  severe,  until  frequently  the  patient 
feels  as  if  death  were  impending  from  suffocation.  The  patient 
sits  up  in  bed,  with  the  windowia  wide  open,  literally  gasping  for 
breath,  and  in  spite  of  the  most  violent  muscular  effort  finds  it 
almost  impossible  to  get  air  into-  or  out  of  the  chest.  ^Vhat  little 
interchange  of  air  occurs  is  accompaniedi  by  loud,  wheezing 
sounds,  which  usually  can  be  heard  at  a  considerable  distance  from 
the  patient.  Cyanosis  is  usually  present,  and  frequently  the  skin 
surface  is  cold  and  covered  with  perspiration.  Not  only  inspira- 
tion is  extremely  difficult,  but  expiration  also,  and  frequently  the 
expiratory  difficulty  is  the  most  marked.  The  distended  chest  and 
diminished  respiratory  movement  of  the  thorax,  in  spite  of  the 
violent  efforts,  present  a  very  characteristic  appearance  on.  inspec- 
tion. 

In  addition  toi  the  labored  respiration  and  visible  evidence  of 
deficient  aeration,  examination  of  the  chest  shows  soft  or  inaudi- 
ble breath-sounds,  their  place  being  taken  by  wheezing  rales; 
expiration  is  markedly  prolonged,  and  the  rales  are  seemingly 
more  marked  during  this  phase  of  respiration.  The  inspiratory 
murmur  may  be  present,  softer  than  normal,  and  only  the  expira- 
tory sound  obscured  by  the  wheezing  rales.  Percussion  is  usu- 
ally negative,  although  tliere  may  be  a  certain  amount  of  hyper- 
resonance  present. 

Expectoration  usually  does  not  appear  until  near  the  end  of 
the  attack,  the  sputumi  as  a  rule  consisting  of  small,  rounded, 
hyaline  granules  or  balls,  translucent  and  grayish  in  color,  these 
characteristic  perles  usually  being  mixed  with  more  or  less  mucus. 
Microscopically,  these  small  sago-like  granules  are  seen  to  have 


BRONCHIAL   ASTHMA.  351 

a  thread-like  structure  arranged  in  a  corkscrew  manner — the 
so-cahed  Curschmann's  sipirals.  The  spiral  arrangement  may  be 
visible  even  to  the  naked  eye,  and  is  easily  demonstrated  under 
the  low  power  of  the  microscope.  Other  distinctive  features  are 
the  presence  of  Charcot-Leyden'  crystals,  and  a  marked  increase 
in  the  proportion  of  eosinophiles. 

TREATMENT. 

The  treatment  of  the  cases  of  dyspnea  which  simulate  bron- 
chial asthma  must  be  directed  toward  the  associated  heart,  kidney, 
or  pulmonary  disease  responsible  for  the  development  of  this 
symptom,.  True  bronchial  asthma,  as  previously  noted,  may 
develop  as  a  result  oif  sienisitization  to  some  foreign  protein,  or 
may  appear  as  a  reflex  nervous  manifestation  from  the  presence 
O'f  some  morbid  condition  in  another  part  of  the  body.  Polyps, 
or  malformations  and  hypertrophic  conditions  in  the  nose,  may  be 
the  exciting  factors,  also  post-nasal  adenoid  overgrowth,  and 
abnormalities  of  the  larynx,  trachea,  and  genitalia.  The  asth- 
matic attacks  have  been  checked  by  correction  of  tliese  abnormali- 
ties, in  many  cases  being  followed  by  an  apparent  cure.  The  first 
istep  in  treating  bronchial  asthma  between  the  attacks  consists  of 
the  correction  of  any  abnormality  of  the  upper  air  passages  or 
genitalia  which  may  exist,  in  the  hope  that  the  case  under  observa- 
tion may  be  of  the  reflex  nervous  type.  The  cases  which  represent 
anaphylactic  phenomena  are  due  to  sensitization  to  a  protein  sub- 
stance, which  may  arise  from  some  latent  focus  of  bacterial 
infection,  such  as  chronic  nasal  sinus  infection,  alveolar  abscess, 
and  infection  of  the  gall-bladder  or  of  the  bronchi  themselves. 
The  focus  of  infection  should  be  sought  for,  and  removed  as  soon 
as  possible,  in  the  hope  of  preventing  the  occurrence  of  further 
attacks.  When  the  attacks  result  from  intoxication  due  toi  sensi- 
tization with  protein  substances  arising  without  the  body,  the 
problem  is  more  complicated. 

Asthma  may  result  from  sensitization  to  the  pollen  of 
certain  weeds  or  grasses  (the  so-called  hay-asthma),  the 
emanations  from  horses  or  other  animals,  or  from  the  inges- 
tion of  certain  foodstuffs,  such  as  egg's,  shell-fish,  or  oatmeal, 
to  mention  only  a  few  of  the  numerous  sourc&s  of  the  protein 
which  possibly  may  be  responsible  for  the  attacks.  To  de- 
termine the  source  of  the  offending  protein  in  the  individual 


352  DISEASES    OF   THE   RESPIR_\TORY   SYSTEM. 

case  may  be  attended  with  considerable  difficulty,  although  a  care- 
fullv  recorded  history  or  close  observation  by  the  patient  may 
suggest  the  probable  nature  of  the  conditions  \\  hich  are  necessary 
for  bringing  on  the  attack.  The  study  of  asthma  from  the  stand- 
point of  its  relation  to  anaphylaxis  has  not  continued  for  a  period 
of  time  of  sufficient  length  for  the.  acciunulation  of  the  necessary 
data  to  render  the  treatment  of  the  disease  from  this  standpoint 
of  that  practical  importance  which  it  will  undoubtedly  reach  in 
the  future. 

The  cutaneous  or  intracutaneous  (not  subcutaneous)  tests 
for  sensitization  to  certain  food  proteins  or  animal  proteins, 
with  the  subsequent  employment  of  the  specific  proteins  in  the 
treatment  of  the  disease,  is  still  in  its  infancy.  These  tests  for 
sensitization  may  be  applied  in  the  following  inarmer:  The  his- 
tory of  the  patient  usualh-  indicates  to  which  group  the  protein 
to  which  they  are  sensitized  belongs,  whether  the  pollens,  animal 
emanations,  foodstuffs,  or  bacteria.  By  applying  to  the  skin  the 
various  proteins  belonging  to  that  group  it  is  frequently  possible 
to  identify  definitely  the  exact  protein  responsible  for  the  attacks. 
For  example,  if  certain  foodstuffs  are  suspected  from  the  history, 
by  careful  questioning  and  obsen^ation  one  may  be  able  to  narrow 
down  the  possible  proteins  to  those  derived  from  meats.  The  solu- 
ble proteins  of  the  various  meats  are  then  secured,  either  by 
making  an  aqueous  extract  of  the  meats,  or  by  dissolving  in 
sterile  water  the  dried  proteins  which  are  now  obtainable  in  a  con- 
venient form  from  the  druggist.  The  skin  of  the  forearm  is  then 
denuded  of  its  superficial  layers  by  means  of  a  von  Pirquet  borer 
at  a  number  of  points,  corresponding  to  the  number  of  tests  it  is 
desired  to  make.  To  one  point  is  applied  normal  salt  solution  or 
a  3  to  5  per  cent,  lactose  solution  for  aj  control,  and  to  each  of 
the  other  points  one  of  the  protein  solutions,  care  being  taken  to 
identify  the  protein  applied  to  each  point.  In  the  case  in  question 
the  solution  of  each  meat  protein  should  be  given  a  number  which 
should  be  marked  on  the  skin,  at  some  distance  from  the  abrasion 
by  means  of  a  blue  pencil.  Care  must  be  used  in  abrading  the 
skin  not  to  draw  any  blood  or  serum,  merely  the  superficial  layer 
of  the  skin  being  removed.  The  protein  to  which  the  patient  is 
sensitized  may  be  recognized  by  the  development  of  a  positive 
reaction  at  the  point  where  it  has  been  applied.  This  reaction  is 
characterized  by  the  development  of  a  well-defined  urticaria-like 


BRONCHIAL   ASTHMA.  3^3 

wheal  surronnded  by  a  zone  of  erythema;  it  appears  within  from 
five  to  ten  minutes,  and  may  last  for  from  one  to  three-quarters 
of  an  hour.  A  slight  swelling  not  infrequently  develops  from  the 
abrasion  of  the  skin,  but  this  false  reaction  should  not  lead  to  any 
confusion,  as,  its  nature  may  be  recognized  by  the  control  test, 
which  also  will  show  the  same  phenomena. 

The  test  may  also  be' made  by  injecting  a  minute  quantity 
(0.01  to  0.02  mils  of  a  1  or  2  per  cent,  solution)  of  the  pro- 
tein directly  into  the  skin  (not  beneath  the  skin)  by  means 
of  a  very  fine  hypodermic  needle  (27-gage).  The  reaction 
is  the  same  as  by  the  other  methods,  and  while  it  is  more 
■delicate  than  tlie  cutaneous  test,  it  usually  takes  longer  for 
it  to  appear,  is  slightly  painful,  and  there  is  a  chance  of  the 
solution  being  injected  beneath  the  skin,  with  the  development 
of  a  general  reaction,  which  in  a  very  isensitive  patient  may  lead 
to  very  alarming  symptoms,  and  possibly  to  death.  For  this 
reason  the  intracutaneous  test  should  be  performed  only  by  one 
accustomed  to  thisi  method  of  application,  the  cutaneous  test  being 
much  more  preferable  for  general  use.  It  is  to  be  hoped  that 
furthei-'  study  will  simplify  the  methods  now  employed  for 
determining  the  protein  to  which  the  individual  has  become  sensi- 
tized, and  the  securing  of  desensitization,  and,  will  shed  some  light 
upon  the  problem  of  why  only  certain  individuals  should  become 
sensitized  to  such  proteins.  The;  entire  question  of  anaphylactic 
phenomena  is  one  about  which  we  know  relatively  very  little  at 
the  present  time. 

The  thorough  study  of  a  case  of  bronchial  asthma  between 
the  attacks  is  a  far  from  simple  rhatter,  but  is  absolutely  essen- 
tial in  the  majority  of  cases,  if  one  expects  to  secure  for  the 
patient  any  permanent  relief.  A  careful  study  of  the  nose, 
throat,  ear,  teeth,  and  in  fact  the  entire  body  for  possible 
abnormalities,  defects,  or  sources  of  infection  may  be  neces- 
sary. The  sputum  also  should  be  carefully  studied,  with  the 
hope  of  determining  whether  the  constant  presence  of  any  cer- 
tain bacteria  in  predominant  numbers  in  the  washed  sputum 
suggests  their  bearing  an  etiologic  relation  to  the  process. 
Certain  strains  of  streptococci,  pneumococci,  and  fusiform 
anerobic  bacteria  have  been  described  as  the  probable  cause  of 
certain  cases  of  asthma,  and  the  experiments  with  the  micro- 
organisms in  some  of  the  cases  seem  to  support  such  views. 

23 


354  DISEASES    OF    THE   RESPIRATORY    SYSTEM. 

When  the  relation  between  the  vegetable,  animal,  or  bac- 
terial protein  and  the  asthmatic  seizures  can  be  definitely  and 
positively  established,  the  treatment  of  the  patient  may  be 
cautiously  begun  by  giving  small  quantities  of  the  offending 
protein, 

Desensitization  may  be  accomplished  in  the  case  of  food 
proteins  by  feeding  the  patient  a  small  quantity  of  the  offend- 
ing food  daily,  gradually  increasing  the  amount  until  the  skin 
reaction  fails  to  develop  or  becomes  very  weak.  It  is  neces- 
sary to  continue  the  ingestion  of  a  moderate  amount  of  the 
food,  otherwise  the  patient  may  become  sensitive  again. 
Wkere  the  patient  is  extremely  sensitive  it  may  be  necessary 
to  begin  the  treatment  with  an  exceedingly  minute  dose, 
which,  if  well  borne,  may  be  rapidly  increased,  the  amount 
again  being  reduced  upon  the  appearance  of  any  toxic 
symptoms. 

For  desensitization  to  the  other  types  of  protein  the  sub- 
cutaneous injection  of  the  protein  may  be  employed,  but  for 
foodstuffs  the  administration  by  mouth  is  to  be  preferred. 
Great  care  must  be  used  in  the  hypodermic  method,  as  serious 
anaphylactic  phenomena  may  follow  the  injection  of  too  large 
a  dose  in  a  very  sensitive  patient.  An  initial  dose  of  0.00001 
milligram  of  the  various  foodstuffs  is  safe  to  use  in  nearly 
every  case,  this  initial  amount  being  gradually  increased. 
Care  must  be  taken  in  increasing  the  dose  to  avoid  causing 
any  toxic  symptoms,  and  if  any  should  appear  the  subsequent 
dose  should  be  well  below  that  producing  the  unpleasant 
symptoms,  and  the  following  dose  being  more  cautiously 
increased.  The  treatment  may  be  continued  until  there  is  no 
longer  a  positive  cutaneous  test  obtainable.  The  hypo- 
dermic injections  should  be  given  under  complete  aseptic  con- 
ditions, using  every  precaution  to  avoid  infection. 

Caution  must  be  emplo^^ed  in  administering  diphtheria 
antitoxin  to  asthmatics,  as  death  has  followed  the- injection  in 
numerous  instances.  Whenever  it  may  become  absolutely 
necessary  to  employ  diphtheria  antitoxin  in  asthmatics,  a  pre- 
liminary skin  test  should  be  made  to  determine  the  patient's 
susceptibility  before  injecting  any  large  quantity  of  the  serum. 
This  is  especially  true  when  the  asthmatic  attacks  have  been 
shown  to  bear  a  definite  relation  to  horses. 


BRONCHIAL  ASTHMA.  335 

The  employment  of  bacterial  vaccines  in  asthmatics  must 
be  used  with  some  caution,  for  the  condition  may  be  a,ygra- 
vated  by  their  use,  although  many  writers  have  had  very 
g-ratifying  results  from  this  form  of  therapy,  especially  when 
autogenous  vaccines  have  been  employed.  The  use  of  tliese 
products  in  this  disease  is  open  to  the  same  objection  which 
holds  true  in  all  broncho-pulmonary  diseases,  namely,  the 
difficulty  in  determining  definitely  the  organisms  causing  the 
disease  process. 

Certain  observers  have  reported  very  gratifying  results 
from  the  subcutaneous  injection  of  autogenous  defibrinated 
blood,  obtained  preferably  during  the  asthmatic  attacks,  as  a 
means  of  active  immunization  to  the  causal  protein. 

Treatment  along  the  lines  suggested  above  for  removing 
or  overcoming  the  cause  of  the  condition  are  frequently  fol- 
lowed by  an  amelioration  o^f  the  symptom,  and  in  many  in- 
stances an  absolute  cure  is  effected.  Unfortunately,  certain 
cases  of  bronchial  asthma  are  encountered  in  which  all  efforts 
to  detect  the  causative  agent  are  of  no  avail,  and  in  which  one 
will  have  to  rely  upon  such  measures  as  tend  to  build  up  the 
general  health  of  the  patient,  improve  the  digestion,  assure  a 
favorable  climate,  and  depend  upon  medication  for  the  relief 
of  the  symptoms.  Occasionally  bronchial  asthma  may  occur 
in  patients  suffering  from  some  other  disease,  such  as  chronic 
heart  disease,  nephritis,  tuberculosis,  bronchitis,  and  emphy- 
sema, in  which  case  the  underlying  disease  must  receive 
appropriate  treatment. 

Of  all  the  various  drugs  recommended  in  this  condition  there 
is  none  which  is  of  so  much  value  between  the  attacks  in  the 
majority  of  cases  as  the  iodid  of  potassium.  In  5-,  10-,  15-,  or 
20-  grain  doses  (0.32,  0.65,  0.97,  or  1.3  Gm.)  three  times  a  day 
after  meals,  preferably  administered  in  essence  of  pepsin,  it 
will  not  infrequently  result  in  complete  relief  of  symptoms  so 
long  as  the  drug  is  continued.  Unfortunately,  the  tendency 
is  for  the  patients  to  relapse  when  the  drug  is  discontinued,  as 
may  be  necessary  from  time  to  time,  on  account  of  gastric  dis- 
turbance, or  the  evidence  of  iodism.  Lobelia  in  the  form  of 
the  tincture  (15  minims,  or  1.0  mil)  may  be  advantageously 
combined  with  the  iodide  in  certain  cases.  While  arsenic  has 
been  recommended  in  the  treatment  between  the  attacks,  and 


356  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

may  be  tried  in  the  event  of  failure  with  other  lines  of  treat- 
ment, the  results  are  as  a  rule  not  very  satisfactory,  and  not  to 
be  compared  with  those  following-  the  use  of  potassium  iodide. 
Atropin  may  prove  of  benefit  in  certain  cases,  the  dose  being 
gradually  increased  until  Y^q  grain  (0.0021  Gm.)  is  reached, 
or  the  symptoms  of  dr}'ness  of  the  throat,  flushing,  or  loss  of 
accommodation  indicate  that  the  physiologic  limit  of  toler- 
ance has  been  reached. 

The  attacks  of  dyspnea,  which  are  extremely  distressing, 
usually  call  for  active  treatment.  The  chronic  sufferer  from 
this  disease  will  soon  learn  by  experience  the  line  of  treat- 
ment affording  the  greatest  relief,  not  infrequently  instituting 
certain  measures  before  the  arrival  of  the  physician.  The 
breathing  is  usually  much  easier  with  an  abundance  of  fresh 
air,  although  care  must  be  taken  to  protect  the  patient's  body 
from  undue  chilling,  as  the  asthmatic  sufferer  will  frequently 
throw  off  all  covering  in  the  effort  to  relieve  the  chest  of  all 
restraint.  The  upright  position,  with  the  arms  braced  to  aid 
the  muscular  efforts  to  breathe,  is  usually  assumed  by  the 
patient  of  his  own  accord. 

When  it  is  certain  that  one  is  dealing  with  true  spas- 
modic asthma,  there  is  no  remed}-  which  is  of  so  much 
value  as  morphin,  given  hypodermically  in  combination  with 
atropin.  For  obvious  reasons,  however,  care  should  be 
taken  in  administering  it,  and  its  use  should  not  be  insti- 
tuted lightly,  and  onl}^  when  other  measures  have  failed.  The 
relief  which  follows  its  use  may  readily  lead  to  the  patient's 
seeking  an  injection  upon  the  slightest  indication  of  dyspnea, 
not  infrequently  with  the  development  of  a  habit  which  leaves 
him  in  a  worse  condition  than  before,  Heroin  may  be  used 
in  its  place,  or  sodium  bromid ;  chloral  hydrate,  while  very 
effective,  in  many  cases  is  too  depressing  to  be  employed  save 
exceptionally.  The  sponging  of  the  nose  and  throat  with  a  5 
per  cent,  cocain  hydrochlorate  solution  is  open  to  the  same 
objection  as  morphin,  namel}^  the  establishment  of  a  habit, 
but  occasionally  it  may  be  employed  with  benefit  in  cases  of 
extreme  severit}^  which  have  failed  to  respond  to  the  other 
measures  suggested. 

For  many  years  the  nitrites  have  been  held  in  high  repute 
for    the    treatment    of    the    paroxysms,    and    in    many    cases 


BRONCHIAL  ASTHMA.  35/ 

deservedly.  Nitroglycerin  (Koo  grain  or  0.00064  Gm.)  hypo- 
dermically,  or  amyl  nitrite  inhalations,  may  give  a  great  deal 
of  relief  when  administered  early  in  the  attack.  The  burning 
of  papers  saturated  with  potassium  nitrate  is  another  popular 
method  of  applying-  this  remedy  through  the  inhalation  of  the 
fumes.  The  smoke  obtained  by  burning  certain  leaves,  such 
as  stramonium,  lobelia,  belladonna,  hyoscyamus,  and  tobacco 
combined  with  powdered  potassium  nitrate  is  a  very  common 
remedy  in  this  affection,  the  powder  being  burned  openly  in 
the  patient's  room,  or  being  used  in  the  form  of  cigarettes. 
The  use  of  these  powders  may  occasionally  prevent  the  occur- 
rence of  attacks  so  long  as  they  are  used,  but  the  effect  soon 
wears  off,  no  relief  being  obtained  from  them  after  being  used 
for  a  short  time,  a  statement  which  is  equally  true  of  many 
of  the  drugs  for  the  relief  of  this  symptom.  A  formula  for 
such  a  powder  which  has  been  recommended  is : 

IJ  Stramonii  foliorum  3iv   (15.5  Cms.). 

Anisi  fructus, 

Potassii  nitratis   aa  Sij    {T .11  Cms.). 

Tabaci  foliorum gr.  v  (0.32  Gm.) . 

A  teaspoonful  (4  mils)  of  the  powder  may  be  burned  on 
a  plate  openly  in  the  room,  or  covered  with  a  cone  through 
which  the  smoke  is  inhaled.  Ipecac,  apomorphin,  and  similar 
drugs  in  some  cases  may  give  considerable  relief,  especially 
in  patients  in  whom  the  dyspnea  is  accompanied  by  a  hard, 
dry  cough. 

Adrenalin  has  of  recent  years  been  very  popular  as  a  means 
of  aborting  the  paroxysms,  and  while  the  effect  is  not  very 
lasting,  the  relief  from  the  dyspnea  is  very  decided  when  this 
animal  extract  is  given  hypodermically  in  doses  of  5  to  15 
minims  (0.32  to  0.97  mil)  of  the  1 :  lOCX)  solution  in  normal  salt 
solution.  The  injections  may  be  followed  by  unpleasant  S3'^mp- 
toms,  such  as  pallor,  chilliness,  palpitation,  and  restlessness, 
but  these  by-effects  are  usually  transient,  and  have  been  con- 
sidered negligible  in  view  of  the  relief  obtained.  While  usu- 
ally considered  harmless,  adrenalin  should  be  used  with 
extreme  caution  when  there  is  organic  disease  of  the  heart  or 
kidneys,  and  cases  of  asthma  in  which  there  was  cardiac  weak- 
ness  or  disease    have   been   reported    in    which    unfavorable 


358  DISEASES    OF    THE    RESPIRATORY   SYSTEM. 

symptoms  of  a  serious  nature  followed  its  injection  in  moder- 
ate doses. 

While  it  seems  hardly  necessary  to  refer  to  the  use  of  the 
various  commercial  "asthma  cures,"  which  depend  largely 
upon  the  presence  of  cocain  for  their  effect,  it  might  be  well 
to  emphasize  the  importance  of  cautioning  patients  suffering 
from  this  disease  about  the  dangers  attending  their  use.  Some 
of  the  commercial  powders  for  burning  in  the  room  contain 
small  amounts  of  powdered  opium,  a  fact  which  impresses  on 
the  physician  the  importance  of  prescribing  personally  a  mix- 
ture for  burning  in  the  patient's  room  rather  than  depend  upon 
the  proprietary  preparations. 

HAY-FEVER    AND    HAY-ASTHMA. 

The  lachr}'mation  and  sneezing,  so  characteristic  of  hay- 
fever  attacks,  may  be  further  aggravated  by  implication  of  the 
bronchial  mucous  membrane,  with  coughing  and  attacks  of 
dyspnea  identical  in  character  with  the  attacks  of  asthma  re- 
sulting from  animal  emanations,  food,  and  similar  irritants. 
The  symptoms  of  hay-fever  are  so  well  known  and  so  char?x- 
teristic  that  they  require  no  further  reference.  The  condition 
is  so  extremely  distressing,  in  spite  of  its  relative  innocuous- 
ness,  that  the  description  of  the  various  methods  of  treatment 
are  of  considerable  interest. 

The  disease  is  caused  by  the  pollen  of  various  plants,  al- 
thoug-h  a  certain  susceptibility  on  the  part  of  the  individual  is 
necessary  for  the  development  of  the  disease.  Bacterial  infec- 
tion and  certain  deformities  of  the  upper  air  passages  seem  to 
bear  an  etiologic  relation  in  some  cases.  While  the  pollens  of 
various  plants  are  capable  of  causing  the  disease,  the  large 
proportion  of  cases  arise  from  the  pollen  of  only  a  few  species, 
the  disease  in  each  individual  being  apparently  due  to  the  pol- 
len of  one  special  plant.  The  attacks  may  occur  at  different 
periods  of  the  year  in  different  individuals,  depending  upon  the 
plant  life  in  different  climates,  but  is  most  common  in  the  late 
summer  (August)  and  early  fall  months.  When  a  person  with 
the  disease  goes  to  a  region  where  the  offending  plant  does  not 
grow,  or  when  such  a  pLant  is  eradicated  from  the  neighbor- 
hood of  the  patient,  the  disease  does  not  occur. 


HAY-FEVER    AND    HAY-ASTHMA.  359 

The  pollen  seems  to  act  in  a  twofold  manner,  direct  and 
indirect,  in  exciting  the  disease.  The  first  is  a  local,  irritating 
etTect  of  the  spiculated  pollen  upon  the  mucous  membrane  of 
the  nose,  while  the  second  excites  phenomena  of  anaphylaxis 
in  sensitized  individuals,  from  the  absorption  of  certain  pro- 
teins or  toxalbumins  contained  in  the  pollen,  the  nasal,  ocular, 
and  bronchial  symptoms  being-  the  evidence  of  anaphylaxis. 
This  indirect  or  anaphylactic  effect  is  far  the  more  important 
and  the  more  common. 

In  the  United  States  the  plants  which  cause  the  greatest 
number  of  cases  are  the  grasses  (timothy,  rye,  and  orchard 
grass),  producing  the  spring  types  of  the  disease,  and  the  rag- 
weeds, cockleburs,  and  wormwoods,  responsible  for  the  late 
summer  and  fall  forms.  It  has  been  shown  that  the  common 
ragweed  (Ambrosia  artemisiaefolia)  and  the  giant  ragweed 
(Ambrosia  trifida)  are  responsible  for  85  per  cent,  of  all  cases 
of  autumnal  hay-fever  in  the  sections  in  which  these  weeds 
are  prevalent.  It  is  of  interest  to  note  what  a  well-organized, 
intelligent  campaign  may  succeed  in  accomplishing  against 
a  single  disease.  The  number  of  hay-fever  cases  in  New 
Orleans  has  been  greatly  reduced  by  a  systematic  destruction 
of  the.  hay-fever  weeds  in  the  vicinity  of  that  city,  the  destruc- 
tion of  the  weeds  being  accomplished  by  education  of  the  pub- 
lic, supported  by  the  necessary  legislation. 

The  general  treatment  of  hay-fever  and  hay-asthma  neces- 
sarily includes  those  measures  suggested  for  the  treatment  of 
asthma,  namely :  correction  of  nasal  defects  and  deformities ; 
the  removal  of  all  possible  sources  of  infection  in  the  nose, 
throat  or  mouth ;  the  elimination  from  the  diet  of  such  food- 
stuffs as  may  possibly  give  rise  to  anaphylactic  phenomena  (as 
determined  by  cutaneous  tests),  and  careful  attention  to  the 
regulation  of  the  bowels.  The  appropriate  treatment  applied 
to  any  associated  bronchitis,  cardiac  weakness,  or  renal  insuffi- 
ciency is  also  indicated. 

The  drugs  which  seem  to  be  of  most  value  are  the  alkalies, 
such  as  sodium  bicarbonate,  which  may  be  given  in  10-  to  15- 
grain  (0.65  to  0.87  Gm.)  doses  every  three  hours  for  a  few 
days,  and  then  reduced  in  amount.  If  the  bicarbonate  of 
sodium  should  give  rise  to  irritation  of  the  g-astric  mucous 
membrane-,  a  small  amount  of  bismuth  subnitrate,  3  to  5  grains 


360         DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

(0.19  to  0.32  Gm.),  may  be  added  to  each  dose  of  the  sodium 
bicarbonate.  Calcium  salts  have  proved  of  considerable  value 
in  certain  cases,  the  lactate  or  chlorid  salt  being-  the  form  in 
which  it  is  usually  employed.  These  calcium  salts  should 
always  be  well  diluted  before  being  administered,  and  are 
preferably  given  after  meals.  Quinin  in  large  doses  and  anti- 
pyrin  have  been  recommended  in  the  treatment  of  this  dis- 
ease, but  the  result  of  their  employment  is  ver}^  likely  to  be 
disappointing. 

The  distressing  nasal  symptoms  ma}^  be  very  much  ame- 
liorated by  warm  alkaline  sprays,  or  by  sprays  of  adrenalin 
solution  (1 :  10,000),  although  the  use  of  this  latter  drug,  while 
very  striking  at  the  time,  is  frequently  followed  by  a  period  of 
aggravation  of  symptoms  as  soon  as  its  effect  has  worn  off. 

When  the  nasal  secretion  is  excessive,  atropin  sulphate, 
%oo  grain  (0.00021  Gm.)  every  two  or  three  hours,  until  dr}^- 
ness  of  the  throat  develops,  may  prove  of  considerable  value. 

In  the  prevention  of  the  disease  the  most  natural  method 
would  be  the  destruction  of  the  weeds,  the  pollen  of  which 
causes  the  disease,  in  the  immediate  neighborhood  of  the  pa- 
tient. This  is  naturally  not  always  possible  or  advisable,  espe- 
cially in  the  cases  of  grass  pollen  sensitization,  and  the  pollen 
may  be  carried  by  the  wind  for  a  considerable  distance.  If  the 
financial  resources  of  the  patient  permit,  he  may  be  relieved 
of  all  symptoms  by  going  several  weeks  before  the  expected 
attacks  to  some  resort  free  of  the  weeds  causing  his  hay-fever. 
Some  patients  experience  considerable  relief  from  an  ocean 
voyage.  The  most  popular  or  these  hay-fever  resorts  are  in 
the  AAHiite  ]\Iountains  of  New  Hampshire,  and  in  the  northern 
part  of  Michigan  or  Wisconsin.  There  are  also  several  resorts 
along  the  New  Jersey  coast  which  are  regarded  as  free  from 
this  disease.  This  method  of  traveling  in  order  to  avoid  the 
attack  of  the  disease,  v^diile,  possibly  agreeable,  is  not  always 
convenient,  and  it  is  only  possible  for  the  wealthy. 

Specific  Treatment.  The  value  of  this  method  of  treatment  is 
at  present  almost  entirely  confined,  to  its  application  as  a  pre- 
ventive measure,  being  of  very  little  (if  any)  value  as  a  cura- 
tive agent.  In  rare  instances  the  disease  has  been  aborted  in 
the  early  stages  by  means  of  pollen  extracts,  but  at  this  period 
its  use  is   not  without  danger,   not  only   of  aggravating  the 


EMPHYSEMA.  361 

symptoms,  but  of  causing-  serious  trouble.  Regardless  of  the 
specific  treatment  employed,  no  measure  should  be  neglected 
which  offers  any  possible  aid  in  preventing  the  recurrence  of 
the  disease. 

The  first  step  in  specific  treatment  is  to  determine  the  pol- 
len responsible  for  the  attacks  by  means  of  the  cutaneous 
tests  described  under  Asthma.  (See  p.  352,  et  seq.)  Having  de- 
termined the  type  of  pollen  to  which  the  individual  is  sensi- 
tized, various  dilutions  of  this  pollen  may  be  employed  in  a 
second  series  of  cutaneous  tests  to  decide  upon  the  initial  dose 
to  be  employed  in  that  individual.  The  largest  amount  which 
fails  to  excite  a  positive  cutaneous  reaction  is  employed  for  the 
first  dose,  which  is  not  g^iven  until  all  symptoms  of  local  cutan- 
eous reactions  have  disappeared.  The  course  of  treatment 
should  be  beg'un  about  eight  we^eks  before  the  attacks  usually 
begin.  Ten  to  15  injections  at  three-day  intervals  are  usually 
required  to  produce  immunity.  If  symptoms  of  hay-fever  or 
asthma  should  develop  during'  the  course  of  the  treatment,  or 
any  signs  of  anaphylactic  reaction,  the  subsequent  injection 
should  be  lower,  and  the  intervals  between  injections  slightly 
increased.  Thei  individual  pollens  should  be  employed  when- 
ever possible.  While  the  mixed  pollens  of  spring  or  fall  types, 
as  usually  supplied  by  the  commercial  houses,  may  be  em- 
plo)'ed,  care  must  be  exercised  in  their  administration.  The 
injections  of  pollen  should  always  be  performed  cautiously, 
care  being  taken  to  see  that  the  initial  dose  is  not  excessive,  as 
an  overdose  may  cause  symptoms  of  an  extremely  serious 
nature.  It  is  uncertain  how  long  the  immunity  persists  after 
such  a  course  of  treatment,  but  it  probably  does  not  last  for 
more  than  two  years,  and  in  certain  cases  it  may  be  quite  im- 
possible to  produce  immunity  artificially.  Some  writers 
believe  that  better  results  are  obtained  if,  in  addition  to  the 
pollen  desensitization,  the  patient  is  treated  with  bacterial  vac- 
cines, preferably  the  autogenous  vaccines. 

EMPHYSEMA. 

Several  different  conditions  are  included  under  the  name 
of  emphysema,  the  most  common  being  diffuse  vesicular 
emphysema,  which  is  characterized  by  a  permanent  overdis- 


362        DISEASES    OF   THE    RESPIRATORY   SYSTEM. 

tension  of  the  air  vesicles,  with  secondary  atrophy  of  the 
alveolar  walls,  which  is  also  known  as  true  larg-e-lunged,  or 
hypertrophic  emphysema.  Senile,  atrophic,  or  small-lunged 
emphysema  occurs  in  elderly  people,  and  consists  of  an 
atrophy  of  the  alveolar  walls  as  part  of  the  general  senile 
atrophy.  In  both  of  these  types  the  process  is  general,  in- 
volving both  lungs  equally,  although  the  process  may  be  more 
marked  in  certain  portions  of  the  lungs.  Local  or  compen- 
satory emphysema,  on  the  contrary,  only  aiifects  certain  por- 
tions of  the  lung  or  lungs,  and  is  secondary  to  some  other 
pulmonary  disease  or  lesion.  It  is  most  commonly  seen  in 
lungs  in  which  a  certain  portion  is  crippled  by  a  destructive  or 
contracting  process,  such  as  pulmonary  tuberculosis,  espe- 
cially when  partl}^  or  completely  arrested,  and  with  cavity 
formation,  or  pulmonary  fibrosis.  The  emphysema  may  occur 
in  the  air-bearing  lung-  tissue  adjacent  to  the  lesion,  or  in  the 
opposite  lung  when  the  disease  causing  it  has  rendered  inactive 
large  portions  of  the  lung,  as  in  pleural  effusion  and  pneu- 
monia. This  compensatory  type  should  be  called  simple  pul- 
monary overdistension,  as  when  the  causative  factor  is  re- 
moved the  lung  may  regain  its  normal  size  and  condition, 
although  it  may  eventually  result  in  true  emphysema  if  the 
overdistension  persists  for  any  length  of  time.  There  is  also 
an  interlobular  or  interstitial  type  of  emphysema,  which  is 
due  to  an  escape  of  air  into  the  interstitial  tissue,  and  has 
nothing  in  common  with  true  emphysema,  corresponding  more 
closely  to  subcutaneous  emphysema. 

The  most  important  type  from  a  clinical  standpoint  is  the 
diffuse  vesicular  emphysema,  the  others  being  more  partic- 
ularly of  pathologic  interest,  with  the  possible  exception  of 
the  compensator}^  emph^^sema. 

Diffuse  Vesicular  Emphysema.  While  some  writers  recog- 
nize this  as  an  idiopathic  or  essential  disease,  from  a  practical 
standpoint  it  is  so  frequently  associated  with  other  lesions  of 
the  bronchi  and  lungs,  which  appear  to  bear  an  etiologic  reU- 
tion,  that  it  should  be  considered  as  almost  invariably  a 
secondary  process.  The  most  common  cause  is  chronic  bron- 
chitis, either  as  a  result  of  infection  or  of  cardiac  insufiEicienc3^ 
Bronchial  asthma  comes  next  in  frequency,  obstruction  or 
compression  of  the   air-passages  being  less  frequent.     That 


EMPHYSEMA.  363 

players  upon  wind-instruments,  glass-blowers,  and  singers  are 
especially  prone  to  this  disease  is  an  observation  or  theory 
which  has  been  handed  down  from  one  medical  generation  to 
another,  but  later  investigations  have  done  much  to  discredit 
this  view.    It  is  essentially  a  disease  of  middle  life  or  old  age. 

The  theories  advanced  to  explain  the  pathogenesis  of 
emphysema  are  varied,  and,  as  a  rule,  unsatisfactory,  one 
group  claiming  that  certain  mechanical  defects  of  the  chest 
wall  are  responsible  for  the  condition,  the  other  group  believ- 
ing that  some  essential  change  in  the  lung  itself  is  the  primary 
cause.  Rigidity  of  the  chest  wall,  as  a  result  of  changes  in  the 
costal  cartilages,  is  a  secondary  phenomenon.  Changes  in  the 
connective  tissue,  elastic  tissue,  nerves,  or  blood-supply  have 
been  variously  described  as  the  essential  conditions  upon 
which  emphysema  depended.  In  the  light  of  our  present 
knowledge  the  most  that  can  be  positively  stated  is  that  re- 
peated or  loog-'continued  distension  of  the  pulmonary  tissue 
may  lead  to  emphysema  in  certain  individuals.  Heredity  is 
supposed  to  be  a  factor  in  a  certain  proportion  of  the  cases. 

The  pathologic  conditions  associated  with  emphysema 
consist  of  an  enlargement  of  the  chest  which  is  most  marked 
in  the  anteroposterior  diameter,  resulting  in  a  barrel-shaped 
thorax.  The  costal  cartilages  in  many  instances  are  less  elas- 
tic and  firmer  than  normal,  and  even  may  be  enlarged  or  calci- 
fied. The  lungs  are  voluminous  and  inelastic,  the  edges  are 
rounded,  and  may  meet  in  the  median  line,  and  usually  are 
of  a  pale  grayish  color,  relatively  dry,  and  deficient  in  coloring 
matter.  In  advanced  cases,  immediately  beneath  the  pleura, 
or  deeper  in  the  lung,  may  be  found  air  vesicles  which  vary 
in  size  from  a  pin-head  to  a  pea,  or  rarely  even  larger.  On 
microscopic  examination  the  alveoli  are  found  to  be  enlarged 
with  an  atrophy  of  the  alveolar  walls,  and  in  certain  areas 
small  vesicles  are  seen  from  the  rupture  of  the  walls  resulting 
in  the  coalescence  of  numerous  alveoli,  which  may  implicate 
one  or  more  infundibula.  Evidence  of  compression  and  ob- 
literation of  the  capillaries  is  usually  present,  and  the  elastic 
fibres  appear  reduced  in  size  and  number  on  account  of  the 
dilatation  of  the  alveoli.  The  signs  of  bronchitis  are  almost 
invariably  present,  and  this  change  may  be  accompanied  by 
peribronchial  induration. 


364         DISEASES   OF  THE  RESPIRATORY  SYSTEM. 

Dyspnea  and  cough  are  constant  symptoms  of  emphysema, 
varying  in  severity  with  the  nature  and  extent  of  the  asso- 
ciated conditions,  such  as  bronchitis,  cardiac  weakness,  and 
the  degree  of  pulmonary  distension.  The  cough  and  expec- 
toration are  in  no  way  peculiar,  and  merit  no  special  con- 
sideration, the  subject  being  considered  in  detail  in  the  sec- 


Fig.  3.— Chest  changes  in  chronic  emphysema  of  the 
large-lunged  type. 

tions  on  Bronchitis  (q.v.).  The  dyspnea  may  only  be  present 
upon  exertion,  the  breathing  being  apparently  normal  when 
the  patient  is  at  rest,  or  it  may  be  constant  and  severe.  In 
certain  cases  the  dyspnea  may  be  paroxysmal,  simulating 
bronchial  asthma,  or  the  asthma-like  attacks  which  occur  in 
chronic  cardiac  disease. 

The  diagnosis  of  emphysema  may  be  made  upon  inspec- 
tion alone  in  many  instances,  especially  when  the  disease  is  of 
long  standing.    Cyanosis  is  almost  always  present,  and,  while 


EMPHYSEMA. 


365 


usually  slight,  may  be  very  severe.  Dilatation  of  the  super- 
ficial veins  is  frequently  present.  The  respiratory  movements 
are  labored,  the  accessory  muscles  of  respiration  being  visibly 
brought  into  play.  The  chest  is  large  and  appears  to  be  in 
a  constant  state  of  expansion,  respiratory  movements  of  the 
chest  being  more  in  the. nature  of  an  up-and-down  motion  of 


Fig.  4. — Same  patient  as  in  Fig.  3.    Note  the  increased  antero- 
posterior diameter  of  the  chest. 

the  anterior  portion  of  thorax,   the   normal   range   of   costal 
movement  being  absent  or  diminished. 

The  antero-posterior  diameter  of  the  chest  is  markedly 
increased  in  relation  to  the  lateral  enlargement,  giving  it  a 
cylindrical  or  barrel-shaped  appearance  on  cross  section,  in 
contrast  to  the  normal  oval  or  kidney-shaped  outline.  This 
may  be  clearly  seen  if  a  tracing  is  made  of  the  outline  of  the 
chest  by  means  of  the  cyrtometer.     The   short,  thick  neck, 


366 


DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


shoulders  high  and  slightl}-  stooped,  prominent  sterno-cleido- 
mastoid  muscles,  the  obtuse  epigastric  costal  angle,  the  en- 
larged barrel-shaped  chest,  and  the  labored  breathing  and 
diminished  respirator}-  excursion  of  tlie  chest  walls  together 
form  a  picture  which  is  absoluteh^  characteristic  in  the  major- 
it}-  of  cases.  Palpation  reveals  diminished  tactile  freinitus,  and 
the  apex  beat  of  the  heart  is  very  feeble,  or  cannot  be  felt  at 
all.  On  percussion,  the  sound  elicited  is  booming,  loud,  and 
low-pitched — hyperresonance,  the  resonance  extending  several 
interspaces  below  the  normal  lower  limits,  or  the  lower  border 


^_ — 

.^ 

.  / 

A 

J 

A 

Fig.  5. — Chest  tracing  of  patient  shown  in  Figs.  3  and  4.  Note 
the  circular  outline,  with  increased  antero-posterior  diameter, 
which  is  characteristic  of  emphysema. 


of  resonance  is  more  easily  determined,  indicating  that  the 
diaphragm  is  less  convex  than  normal,  and  that  the  pulmonary 
lower  edge  is  more  voluminous  and  thicker  than  in  the  healthy 
lungs.  The  axea  of  so-called  absolute  cardiac  dullness  (cardiac 
flatness)  may  be  diminished  or  absent,  resonance  being  ob- 
tained over  the  entire  precordia.  The  inspiratory  excursion,  as 
measured  bv  the  movement  of  the  lower  border  of  resonance, 
is  distinctly  diminished.  The  upper  borders  of  hepatic  and 
splenic  dullness  are  lower  than  normal,  and  more  difhcult  to 
map  out.  Auscultation  reveals  a  prolonged,  soft,  low-pitched 
expiratorv  murmur,  when  not  obscured  by  the  sonorous  or 
sibilant  rales,  which  are  usually  of  prolonged  duration,   al- 


EMPHYSEMA.  367 

though   the    rales   may   be    at  times  distinctly    moist    and   of 
varying-  size. 

The  various  changes  in  the  heart  as  a  result  of  increased 
resistance  in  the  pulmonary  circuit  can  usually  be  determined, 
especially  in  the  right  heart.  The  ,r-ray  may  be  necessary  to 
determine  the  exact  size  of  the  heart,  and  may  be  used  to 
confirm  the  physical  findings.  The  diminished  expansion  also 
may  be  further  studied  by  means  of  chest  measurements  or 
with  the  spirometer. 

TREATMENT. 

The  treatment  of  true  emphysema  consists  mainly  in  the 
control  of  such  secondary  conditions  as  may  aggravate  or  be 
responsible  for  the  symptoms,  no  means  in  our  possession  at 
the  present  time  being  capable  of  actually  overcoming  the 
overdistension  of  the  alveoli  and  renewing  their  contractility. 

The  dyspnea  may  be  relieved  in  certain  cases  by  treatment 
directed  toward  correcting  abnormalities  of  the  circulatory 
organs  or  relieving  diseased  kidneys.  In  gouty  or  rheumatic 
subjects  some  relief  may  be  obtained  by  treatment  of  the 
underlying  systemic  disease.  There  is  no  condition  outside 
of  the  bronchial  catarrh  which  seems  to  aggravate  this  symp- 
tom to  so  marked  a  degree  as  disturbances  of  digestion,  espe- 
cially when  associated  with  gaseous  fermentation  in  either 
the  stomach  or  the  intestines.  Careful  attention  to  diet,  and 
the  correction  of  any  tendency  to  constipation,  with  such 
medication  as  may  be  indicated  to  correct  the  disturbances  of 
the  gastro-intestinal  tract,  will  in  certain  cases  be  invaluable 
in  the  relief  of  the  symptoms  of  this  condition. 

The  commonly  associated  bronchitis  is  usually  very  re- 
sistant to  treatment,  and  is  the  symptom  toward  the  relief  of 
which  most  of  the  medication  will  have  to  be  directed.  In 
the  majority  of  cases,  the  degree  of  comfort  which  the  suf- 
ferers from  this  disease  enjoy  is  in  direct  proportion  to  the 
extent  to  which  the  bronchitis  may  be  controlled.  The  section 
on  the  treatment  of  Bronchitis  (I'.s.)  could  be  inserted  under 
this  section  with  perfect  propriety.  The  bronchitis  may  be 
spasmodic  in  character,  simulating  an  attack  of  asthma,  in 
which  event  such  remedies  as  lobelia,  belladonna,  and  potas- 
sium  iodid   may   prove   of  benefit.      Morphin   in   such   cases 


368  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

should  be  employed  with  the  greatest  caution,  and  never  in 
cases  accompanied  by  evidence  of  marked  bronchitis  or  bron- 
chiolitis. "When  there  is  considerable  wheezing,  usually  occur- 
ring in  spells,  relief  may  be  obtained  by  counterirritation  of 
the  chest  with  mustard,  iodin,  or  turpentine,  and  by  the  ad- 
ministration internally  of  potassium  iodid. 

When  cyanosis  is  present,  digitalis  and  active  purgation 
may  prove  of  benefit,  and  in  rare,  severe  cases,  venesection 
may  become  necessary.  The  general  condition  of  the  patient 
should  be  very  carefully  watched,  and  everj^  measure  resorted 
to  which  will  tend  to  improve  it.  The  questions  of  clothing, 
bathing,  sleeping,  and  dietary'-  should  be  made  the  subject  of 
a  detailed  study,  and  the  patient  instructed  in  regard  to  the 
amount  and  character  of  the  exercise,  and  warned  of  the  neces- 
sity of  avoiding  overexertion  and  fatigue. 

W^here  circumstances  permit,  the  patient  should  live  in 
that  climate  which  seems  to  relieve  him  of  his  symptoms  and 
provide  the  greatest  amount  of  comfort,  the  selection  of  the 
climate  being  dependent  upon  personal  idiosyncrasies  for 
which  we  have  no  tixed  rules  for  guidance.  It  will  usually  be 
the  climate  in  which  the  patient  is  least  likely  to  be  aftected 
with  attacks  of  bronchitis. 

Various  mechanical  devices,  such  as  pneumatic  cabinets  of 
various  kinds,  have  been  recommended  in  the  treatment  of 
emphysema,  and  while  considerable  ingenuit\-  has  been  dis- 
played in  their  construction,  the  results  obtained  from  their 
employment  haA-e  not  been  sufhciently  successful  to  warrant 
their  being  generally  employed.  Breathing  exercises,  mas- 
sage, forcible  compression  of  the  chest,  and  similar  measures 
may  be  employed  with  occasional  benefit,  especially  in  the 
earlier  stages  of  the  disease. 

Emphysema  is  extremely  resistant  to  treatment,  and  the 
best  that  can  be  expected  is  an  amelioration  of  the  symptoms. 
As  previously  stated,  the  medication  employed  must  be 
directed  toward  the  correction  of  the  abnormalities  present  in 
the  other  organs  of  the  body,  or  the  relief  of  the  associated 
conditions  which  aggravate  the  symptoms.  In  some  cases 
str\-chnin,  atropin,  and  caffein  may  be  administered  with 
some  benefit,  in  addition  to  the  other  lines  of  treatment  sug- 
gested.    Adrenalin  has  been  recommended  in  those  cases  in 


EMPHYSEMA.  369 

which  the  cough  is  of  a  spasmodic  character,  and  where  per- 
sistent wheezing-  is  so  marked  as  to  constitute  a  very  distress- 
ing symptom.  The  employment  of  the  drugs  just  mentioned 
must  necessarily  be  undertaken  with  a  certain  amount  of 
caution,  and  only  where  no  contraindication  exists. 

It  is  too  soon  to  draw  conclusions  as  to  the  utility  of  surg- 
ical interference,  based  on  Freund's  theory  of  costal  cartilage 
changes,  The  uncertainty  existing  in  regard  to  the  theory 
upon  which  these  measures  are  based  should  make  one  ex- 
tremely doubtful  of  the  value  of  the  surgical  measures  sug- 
gested. 

Compensatory  Emphysema.  The  pathologic  process  is  the 
same  as  in  the  type  just  described,  with  the  exception  that 
only  portions  of  one  or  both  lungs,  or  one  entire  lung,  is 
affected  instead  of  a  generalized  lesion  of  both  lungs.  The 
condition  may  not  be  demonstrable  clinically,  but  when  so 
marked  as  to  be  recognizable  the  physical  signs  are  the  same 
as  those  of  diffuse  vesicular  emphysema.  The  process  attains 
its  greatest  clinical  interest  in  those  cases  of  pleural  effusion, 
pulmonary  tuberculosis,  or  pulmonary  fibrosis,  in  which  the 
unaffected  lung  may  become  markedly  overdistended,  on 
account  of  loss  of  function  of  the  greater  part  of  one  lung. 
The  one-sided  pulmonary  dilatation  may  interfere  with  the 
usual  physical  findings  in  such  conditions,  and  may  tend  to 
mask  deep-seated  processes  developing  in  the  emphysematous 
lung. 

This  compensatory  type  of  emphysema  is  in  reality  a  func 
tional  hypertrophy,  or  at  least,  it  should  be  looked  upon  as 
such  a  condition,  and  hence  it  requires  no  special  treatment 
other  than  that  directed  toward  the  process  which  has  caused 
its  development.  When  the  dilatation  has  persisted  for  some 
time,  the  condition  may  become  permanent,  giving  rise  to  the 
symptoms  associated  with  the  diffuse  vesicular  type,  in  which 
case  the  same  line  of  treatment  should  be  pursued  as  sug- 
gested for  the  latter  condition. 

Senile  Emphysema.  The  senile,  or  atrophic,  form  of  em- 
physema is  an  evidence  of  the  wasting  which  takes  place  in 
the-  aged,  the  lung  sharing  in  the  general  atrophic  or  involu- 
tion process  affecting  the  entire  body.  The  elasticity  of  the 
lungs  is  diminished^  the  chest  assuming  a  position  approaching 


370 


DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


that  of  permanent  inspiration.  The  lungs  are  smaller  than 
normal,  in  distinct  contrast  to  the  other  forms  of  emphysema 
above  described. 

The  symptoms  are  not  nearty  so  marked  as  in  the  diffuse 
vesicular  form.  There  ma}'  be  little  or  no  dyspnea  present, 
owing  to  the  limited  capacity  for  physical  exertion  due  to 
the  general  muscular  weakness.  Where  marked  bronchitis 
is  associated  with  the  process,  spasmodic  attacks  of  severe 
dyspnea  may  occur.  The  patients  present  a  general  atrophic, 
withered  appearance,  without  the  evidences  of  venous  obstruc- 
tion so  commonly  seen  in  the  hypertrophic  type.     The  chest 


/ 

/ 

5 

J 

Fig.  6. — Chest  tracing  in  senile  emphysema  of  the  atrophic  or 
small-lunged  type.  The  retraction  on  the  left  side  anteriorly  is  dtle 
to  an  old  fibroid  process. 

presents  a  rounded  appearance,  not  as  a  result  of  increase  in 
the  antero-posterior  diameter,  but  as  a  result  of  a  general 
shrinkage  which  mainty  affects  the  lateral  diameter.  The  ribs 
assume  a  more  oblique  direction,  the  interspaces  over  the  lower 
portion  of  the  chest  being  narrowed  or  even  obliterated.  The 
signs  are  similar  to  those  found  in  diffuse  vesicular  emphy- 
sema, except  that  there  is  no  evidence  of  enlargement  of  the 
lungs,  and  the  expiration  is  not  prolonged  to  the  same  extent. 
The  senile,  small-lunged  type  of  emph3^sema  should  be 
treated  as  one  would  treat  the  diff'use,  large-lunged  type,  and 
the  prospect  of  improvement  in  the  senile  type  is  even  worse 
than  in  the  latter  form. 


PULMOiNARY    TUBERCULOSIS.  371 

PULMONARY    TUBERCULOSIS. 

The  tubercle  is  the  basis  of  practically  all  pathologic  processes 
resulting  f roiii  an  implantation  of  tubercle  bacilli  in  tissues  favor- 
able to  their  growth.  MicroscoiDically,  the  tubercles  in  the  early 
stages  of  their  development  present  a  characteristic  appearance, 
the  center  being  occupied  by  giant  cells  and  epitheloid  cells  sur- 
rounded by  a  zone  of  concentrically  arranged  epitheloid  cells, 
around  which  is  arranged  a  zone  of  round  cell  infiltration  com- 
posed principally  of  lymphocytes.  The  subsequent  changes  in  the 
tubercle,  whether  caseation  or  conversion  of  the  tubercle  into- 
fibrous  scar  tissue  occur,  are  of  considerable  clinical  interest. 
Even  when  caseation  takes  place  in  a  tubercle,  it  may  become 
encapsulated  by  fibrous  connective  tissue,  the  contents  undergoing 
softening  and  evacuation,  or  becoming  inspissated,  and  pos- 
sibly calcified. 

The  extent  to  which  either  of  these  processes,  caseation  or 
sclerosis,  predominates  in  the  individual  case  of  pulmonary  tuber- 
culosis largely  determines  the  clinical  course  of  the  disease. 

The  first  foci  of  pulmonai-y;  tuberculosisi  usually  are  found  in 
the  region  of  the  apex  of  the  lung,  at  a  point  slightly  below 
(about  1^  inches  [3.81  cm,.])  the  extreme  apex,  and  usually 
nearer  tO'  the  posterior  than  to  the  anterior  border  of  the  lung. 
The  process  may  be  lirnited  to)  this  region  or  it  may  extend  until 
the  entire  upper  lobe  is  gradually  infiltrated.  As  the  process 
extends  downward  the  lower  lobe  may  become  afifected,  and  at 
this  time  it  is  extremely  common  to  find  evidence  of  isiome  infil- 
tration in  the  other'  lung,  either  at  the  apex  or  at  the  root. 

The  appearance  of  the  lesion  varies  greatly  in  different  cases, 
depending  upon  whether  the  destructive  or  reparative  process 
predominates,  and  upon  the  course  taken  by  the  disease  in  its 
extension.  There  may  be  numerous  minute  tubercles  or  large 
conglomerate  tubercles,  the  disease  progressing  by  the  direct 
enlargement  of  the  tubercle,  and  by  the  development  of  fresh 
deposits  in  its  immediate  neighborhood.  The  portion  of  lung 
invaded  may  be  merely  the  peribronchial  tissues  or  the  alveolar 
parenchyma,  A  large  portion  of  the  lung  tissue  may  be  affected 
by  a  caseous  pneumonic  process,  or  the  tubercles  may  be  dissemi- 
nated, with  air-bearing  tissue  remaining  between  them.  The 
recent  tuberculous  areas  are  occasionally  found  surrounded  by  a 


372  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

zone  of  congestion,  which  varies  greatly  in  extent.  More  fre- 
quently a  certain  amount  of  sclerosis  surrounds  the  tuberculous 
areas,  limiting  their  growth  by  extension.  The  amount  of  fibrous 
tissue  is  extreme  in  some  cases,  thick  bands  of  scar-like  tissue 
surrounding  the  tuberculous  areas  and  extending  into  the  mass, 
or  with  fibrinous  strise  running  out  into  the  lung.  The  sclerosis 
in  some  cases  may  be  the  only  evidence  of  the  disease,  where  the 
fibrosis  has  followed  closely  upon  each  fresh  extension  of  the 
process. 

^^"here  large  areas  of  the  lung  tissue  have  been  crippled  by 
tuberculosis  of  the  proliferative  type,  extensive  patches  of  casea- 
tion may  be  seen,  in  which  softening  may  or  may  not  be  present. 
Softening  and  liquefaction  of  the  areas  of  caseous  degeneration 
lead  to  the  formation  of  cavities,  the  walls  of  which  are  usually 
formed  by  fibrous  tissue.  It  is  uncomimon  to  find  extensive  areas 
of  softening  and  liquefaction,  with  the  fomiation  of  very  large 
cavities,  in  rapidly  progressing  cases,  nimierous  small  cavities 
being  more  commonly  present  in  this  group  of  lesions.  Cavity 
formation  usually  takes  place  when  areas  of  dense  infiltration 
have  been  walled  off  from  the  rest  of  the  lung  by  scar  tissue. 

The  healing  of  pulmonary  tuberculosis  consists  of  the  forma- 
tion of  fibrous  tissue  about  the  tubercles,  and  v\'hen  the  tubercles 
are  small  the  result  may  be  a  complete  conversion  into  scar  tissue, 
no  evidence  of  tuberculosis  remaining.  Large  tubercles  in  which 
caseation  has  occurred  may  be  walled  off,  inspissated,  and  later 
calcified.  When  the  tubercles  are  very  large  they  may  also  become 
walled  ofif,  the  contents  tmdergoing  liquefaction,  and  persisting  as 
a  closed  abscess  cavity,  or  it  may  rupture  into  a  bronchus  with 
the  evacuation  of  its  contents  through  that  channel.  Cavity  for- 
mation should  be  looked  upon  as  a  healing  or  reparative  process 
in  probably  the  majority  of  instances.  This  is  especially  true  of 
the  small  cavities  occurring  at  the  apex,  with  the  evidence  of  only 
a  slight  amount  of  additional  implication  of  the  lung.  While 
bronchiectatic  cavities  may  occur  in  tuberculosis,  they  are  not 
common,  being  most  frequently  seen  in  the  fibroid  types  of  the 
disease.  Extreme  cavitation  of  the  entire  lobe,  or  even  one  entire 
lung,  occasionally  may  be  present. 

Tuberculous  Resistance.  The  character  of  the  disease 
process  which  develops  as  a  result  of  an  implantation  of  tubercle 
bacilli  varies  greatly  in  different  individuals,  ages,  and  races.    The 


PULMONARY   TUBERCULOSIS.  Z7Z 

conditions  which  influence  the  nature  of  this  tissue  response  to 
the  tubercle  bacilli  do  not  depend  upon  the  virulence  of  the  invad- 
ing micro-organisms,  as  this  has  been  shown  to  be  almost  con- 
stant. The  accidental  location  of  the  infection  plays  a  part  in 
determining-  the  resulting  process,  not  only  the  organ  which  it 
aftects,  but  also  the  relation  of  the  tubercle  to  blood-vessels  and 
lymphatic  channels,  and  possibly  the  severity  of  the  infection,  as 
indicated  by  the  number  of  invading  bacteria,  and  whether  it 
represents  a  primary  infection  or  not.  The  most  important  factor 
seems  to^  be  the  property  possessed  by  the  tissues  to  react  tO'  the 
presence  of  the  invading  microi-organisms  in  various  ways,  which 
has  been  called  resistance,  for  lack  of  more  definite  knowledge  of 
the  mechanism  6f  the  process.  The  degree  of  resistance  to 
tubercle  bacilli  varies  tO'  a  marked  extent  in  different  individuals, 
resulting  in  a  process)  which  ranges  from  the  rapidly  progressing 
form  of  tuberculous  disease  to  the  type  in  which  the  infection 
does  not  result  in  any  actual  disease  at  all;  the  tubercle  bacilli 
being  completely  walled  off  by  connective  tissue  from  the  sur- 
rounding tissues.  This  complete  walling  off  of  the  invading 
bacilli  constitutes  the  nearest  approach  to  immunity  that  has  been 
demonstrated  in  man.  The  immunity  is  therefore  at  its  best  only 
relative,  being  an  immunity  to  the  development  of  disease,  but 
not  toi  infection.  Even  in  those  cases  in  which  the  primary  im- 
plantation is  walled  offi  from  siurrounding  tissue  the  bacilli  may 
remain  dormant  for  years,  retaining  their  viability  and  pathogeni- 
city, and  it  is  possible  for  these  bacteria  tO'  develop  and  to  set  up 
a  morbid  process  whenever  conditions  favorable  to  such  develop- 
ment arise.  Upon  this  peculiar  ability  to  lie  dormant  for  years 
is  based  the  theory  that  all  primary  infections  occur  in  early  child- 
hood, the  disease  arising  in  later  life  being  viewed  as  a  transfor- 
mation O'f  the  early  infection  into  an  active  process,  or  possibly 
in  some  cases  as  the  result  of  a  secondary  infection,  the  theory 
being  that  the  primary  infection  rarely  is  immediately  followed 
by  tuberculosis,  pearly  every  individual  possessing  the  ability  to 
wall  off  the  first  implantation.  The  subject  is  one  that!  involves 
many  different  factors,  and  many  questions!  remain  which  are  far 
from  being  positively  settled.  It  is  unfortunate  that  we  have  no 
means  at  the  present  time  of  accurately  determining  the  relative 
resistance  in  the  individual  case,  as  upon  this  fact  depends  not 
only  the  question  as  to  whether  infection  alone  or  tuberculous  dis- 


374  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

ease  results,  but  also  the  general  character  of  the  disease  process. 
Some  writers  believe  that  the  development  of  pulmonary  tubercu- 
losis is  determined  by  the  presence  of  certain  anatomic  changes 
in,  or  abnormalities  of,  the  chest  wall.  The  ossification  of  the 
costal  cartilage  and  tlie  shortening  of  the  ribs  lead  to  stenosis  of 
the  bony  thorax,  the  first  rib  being  especially  afTected.  The 
theory  is  plausible,  and  while  it  does  not  fully  explain  the  tend- 
ency to  the  development  of  tuberculosis  of  all  cases,  these 
deformities  of  the  thorax  seem)  to  play  a  very  important  role  in 
many  tuberculous  subjects. 

From  the  'clini'cal  standpoint,  it  is  extremely  important  to  bear 
in  mind  that  it  is  possible  to  have  an  infection  without  definite 
tuberculous  disease,  and  it  is  of  equal  moment  to  be  able  to  dis- 
tinguish between  thei  two  cooditionsi.  Upon  this  ability  to  make 
a  distinction  between  infection  and  disease  will  depend  the 
accuracy  of  the  prognosis  and  the  necessity  for  treatment,  and 
upon  the  ability  to  estimate  the  degree  of  resistance  in  the  indi- 
vidual instance,  as  evidenced  by  the  type  and  character  of  the 
tuberculous  procesis,  will  depend  the  ability  to  institute  the  proper 
method  of  treatment.  While  what  has  been  said  applies  especially 
to  pulmonary  tuberculosis,  it  is  equally  true  of  the  disease  when 
implanted  in  other  parts  of  the  body. 

Von  Pirquet's  Test.  Infection  with  tubercle  bacilli  does  not 
always  result  in  tuberculous  disease,  probably  the  majority 
of  infections  giving  no  evidence  of  their  presence  during  the 
life  of  the  infected  individual.  The  presence  of  such  infec- 
tions may  be  determined  by  the  Von  Pirquet  cutaneous  tuber- 
culin test,  applied  in  the  following  manner:  The  skin  of 
the  arm  or  forearm  is  cleansed  and  dried  with  a  piece  of 
sterile  gauze.  By  means  of  a  Von  Pirquet  borer  the 
superficial  layers  of  the  epidermis  are  removed  at  three 
points  about  1  to  2  inches  (2.54  to  5.08  cm.)  apart,  in  a 
line  parallel  to  the  long  axis  of  the  arm.  The  dentral  point  is 
allowed  to  remain  undisturbed,  to  serve  as  a  control.  A  small 
quantity  of  Koch's  old  tuberculin  is  applied  to  the  distal  and 
proximal  points  by  means  of  a  glass  rod,  and  gently  rubbed 
into  the  skin.  After  allowing  the  tuberculin  to  remain  in  con- 
tact with  the  skin  for  five  or  ten  minutes,  the  surplus  is  re- 
moved and  the  surface  allowed  to  dry.  After  the  tuberculin 
has  become  sufficiently  dried  by  exposure  to  the  air,  the  points 


PULMONARY   TUBERCULOSIS.  375 

of  inoculation'  are  covered;  with  a  piece  of  sterile  gauze,  held  in 
position  by  narrow  adhesive  straps,  which  are  not  permitted 
completely  to  encircle  the  arm.  The  gauze  should  be  removed 
at  the  end  of  twenty-four  hours,  and  the  inoculated  points 
inspected.  If  no  reaction  is  evident,  the  examination  should 
be  repeated  at  the  end  of  another  twenty-four  hours.  A  posi- 
tive reaction  shows  a  distinct  redness  and  elevation  in  the 
region  of  the  points  at  which  the  tuberculin  has  been  applied, 
in  contrast  to  the  control  point.  The  reaction  may  appear 
within  a  few  hours  after  the  test  has  been  applied,  but  usually 
persists  for  a  sufficient  time  to  be  evident  at  the  end  of  twenty- 
four  hours.  Frequent  inspection  after  the  test  has  been  ap- 
plied is  prc^ably  safer,  but  is  not  always  practicable.  The 
induration  in  and  about  the  inoculated  points  may  persist  for 
several  days.  If  the  first  application  of  the  test  is  negative, 
it  may  be  repeated  at  the  end  of  a  week,  or  even  a  third  test 
may  be  necessary.  A  positive  reaction  merely  indicates  that 
the  individual  has  at  some  time  been  infected  with  tuber- 
culosis, and  this  should  never  be  interpreted  as  an  indication 
that  active  tuberculous  disease  is  present.  The  determination 
of  actual  tuberculous  disease  is  much  more  difficult,  and  de- 
mands a  careful  inquiry  into  the  patient's  previous  history,  a 
minute,  detailed  record  of  the  symptoms,  and  a  thorough  ex- 
amination of  the  suspect,  including  such  laboratory  and  clin- 
ical aids  as  may  be  of  value. 

The  diagnosis  of  tuberculosis  by  means  of  complement 
fixation  tests  has  been  receiving  considerable  attention  in 
recent  years.  The  method  has  not  been  applied  to  a  sufficient 
number  of  cases  to  warrant  one  in  drawing  positive  conclu- 
sions from  the  results  obtained,  as  to  whether  it  will  ultimately 
prove  of  value  in  the  diagnosis  or  prognosis  of  tuberculosis. 
It  is  to  be  hoped  that  further  investigation  and  observation 
will  result  in  providing  a  method  of  examining  the  blood  which 
will  be  of  value  in  the  diagnosis  of  the  presence  of  tuberculous 
disease,  and  will  supply  a  means  of  estimating  the  degree  of 
activity  of  the  process. 

Too  much  emphasis  cannot  be  laid  upon  the  importance 
of  determining  which  cases  are  in  need  of  radical  treatment 
owing  to  the  presence  of  actual  disease.  The  diagnosis  of 
tuberculosis  conveys  to  the  patient's  mind  a  picture  of  "con- 


376  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

sumption."  with  all  the  misery,  pain,  and  discomfort  which 
that  name  suggests.  The  very  word  tuberculosis  implies  to 
most  people  a  breaking  up  of  their  home  and  a  rearrangement 
of  their  entire  life,  with  usually  a  serious  economic  sacrifice. 
With  the  prevalent  views  in  regard  to  the  contagiousness  of 
the  disease,  the  diagnosis  also  entails  the  placing  of  a  certain 
stigma  upon  the  person  affected,  from  the  effect  of  which  he  may 
never  fully  recover.  It  is  extremely  important,  therefore,  that 
every  care  should  be  used  in  making  a  diagnosis  of  tuber- 
culosis to  avoid  placing  such  a  burden  upon  an  individual 
unnecessarily.  It  is  equally  important  that  the  diagnosis  of 
tuberculosis  should  be  made  in  every  individual  suffering  from 
tuberculous  disease  at  a  time  when  the  lesion  is  slight,  before 
the  lung  has  been  very  much  damaged,  in  order  that  the  proper 
line  of  treatment  may  be  instituted  during  a  period  when  his 
chances  for  recovery  are  at  their  best,  so  that  it  may  be  pos- 
sible to  restore  him  to  full  working  capacity.  Having  made  a 
diagnosis  of  tuberculous  disease,  it  is  imperative  that  the 
patient  be  informed  of  the  fact,  if  one  expects  to  receive  the 
co-operation  of  the  patient  in  carrying  out  the  necessary 
remedial  and  preventive  measures.  As  the  hope  of  recovery 
can  be  held  out  to  the  majority  of  patients,  there  is  no  reason 
why  the  patient  should  not  be  informed  of  the  nature  of  the 
disease  from  which  he  is  suffering,  except  possibly  in  rare 
instances  where  extraordinary  circumstances  may  exist. 

In  taking  a  history  of  the  family  or  of  previous  diseases  it 
is  advisable  to  accept  no  statement  of  a  patient  on  faith,  every 
effort  being  made  to  substantiate  or  disprove  every  statement 
by  careful  cross-examination.  This  is  especially  important  in 
regard  to  the  disease  which  may  have  caused  the  death  of  any 
member  of  his  family,  or  from  which  he  may  have  suffered. 
By  having  him  describe  the  symptoms  of  the  illnesses  in 
detail,  it  is  frequently  a  simple  matter  to  show  that  the  name 
given  by  the  patient  to  the  disease  is  misleading,  if  not 
erroneous. 

The  previous  history  of  the  patient  should  not  be  confined 
to  attacks  of  illness,  but  should  include  an  inquiry  into  the 
general  health  and  strength  of  the  individual,  dating  back  to 
early  childhood  whenever  possible,  and  whether  they  have 
been  subject  to  such  minor  (?)  complaints  as  colds,  la  grippe, 


PULMONARY    TUBERCULOSIS.  ^    Z77 

bronchitis,  indigestion,  and  similar  maladies.  In  determining^ 
the  mode  of  onset  of  the  present  illness,  the  previous  health 
and  symptomatology  of  the  individual  the  greatest  care  must 
be  exercised,  as  upon  the  information  obtained  alone,  in 
the  large  majority  of  instances,  it  is  possible  to  make  a  diag- 
nosis of  tuberculous  disease,  the  physical  examination  being 
merely  necessary  to  confirm  the  diagnosis,  localize  the  disease, 
and  to  determine  the  extent  and  character  of  the  lesions.  The 
physical  examination  is  mainly  of  value  from  the  standpoint 
of  prognosis  and  treatment,  rather  than  diagnosis,  in  a  large 
proportion  of  cases.  Many  practically  healthy  persons  pre- 
sent physical  signs  of  some  abnormality  at  an  apex  of  the  lung, 
but  no  one  can  suffer  from  active  tuberculosis  of  the  lungs 
without  symptoms,  even  if  in  certain  cases  it  may  be  impos- 
sible to  locate  the  focus  of  disease.  It  must  be  apparent  w^hy 
it  is  necessary  to  go  into  the  question  of  symptoms  in  the  most 
thorough  manner,  especially  as  it  requires  no  special  training, 
such  as  physical  diagnosis  demands. 

The  mode  of  onset  varies  greatly  in  different  cases.  In 
some  the  symptoms  referable  to  the  respiratory  tract  pre- 
dominate ;  in  others  the  symptoms  are  in  a  general  v^ay  merely 
suggestive  of  a  chronic  toxemia.  The  various  clinical  pictures  of 
the  early  stages  of  the  tuberculous  disease  may  be  easily  formu- 
lated, when  one  realizes  that  it  is  usually  diagnosed  "typhoid 
pneumonia,"  t3^phoid  fever,  malaria,  chronic  bronchitis, 
chronic  gastritis,  neurasthenia,  anemia,  and  chlorosis.  The 
only  type  which  should  cause  any  confusion  is  that  in  which 
the  earliest  and  most  prominent  symptoms  are  referable  to  the 
gastro-intestinal  tract,  since  in  these  examples  of  the  disease 
the  symptoms  which  should  direct  attention  to  the  possible 
presence  of  pulmonary  tuberculosis  may  be  relatively  slight. 

The  various  symptoms  which  may  suggest  the  presence  of 
pulmonary  tuberculosis  will  be  considered  under  separate  head- 
ings. It  is  'to  be  regretted  that  space  will  not  permit  their  receiv- 
ing that  detailed  consideration  their  importance  deserves. 

Cough  and  Expectoration.  Cough  is  the  most  common  symp- 
tom, of  phthisisi,  and  in  the  nrnjority  of  cases  the  one  which  first 
attracts  the  attention  of  the  patient.  The  coiigh  may  be  transient, 
occurring  only  during  the  winter  months,  or;  it  may  persist  for  a 
long  period  of  time ;  it  is  usually  worse  at  night  on  retiring,  or  on 


378  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

rising  in  the  morning,  and  in  some  patients  the  attacks  occur 
after  eating.  There  is  no  characteristic  of  the  cough  which  is  at 
all  peculiar  to  pulmonar}-  tuberculosis;  it  may  merely  be  a  mild 
hacking  cough,  or  may  be  extremely  severe  and  exhausting,  and 
the  spells  may  occur  in  paroxysms,  or  may  be  followed  by  vomit- 
ing. This  "emetic  cough,"  as  it  has  been  called,  is  believed  to 
have  considerable  significance  as  an  indication  of  the  presence  of 
pulmonar}^  tuberculosis,  in  those  cases  in  which  pertussis  can  be 
ruled  out.  The  cough  is  usually  accompanied  by  the  expectora- 
tion of  mucopurulent  material  in  anyone  in  which  the  disease  is 
of  any  prolonged  duration  or  considerable  extent.  In  some  the 
expectoration  is  not  noticeable,  on  account  of  its  being  uncon- 
sciously swallowed,  or  the  patient  is  unable  to  expectorate  the 
material  coughed  up.  This  is  especially  true  in  children,  where 
it  is  frequently  impossible  to  secure  material  for  an  examination. 
In  some  cases  the  expectoration  is  brought  up  and  expelled  with- 
out anv  apparent  cough  accompanying  the  process.  The  amount 
and  character  of  the  expectoration  varies  with  the  character  and 
location  of  the  pulmonar}-  process,  and  the  extent  to  which  bron- 
chitis accompanies  the  tuberculous  disease. 

\M-iile  the  amount  of  cough  and  expectoration  usually  bear  a 
definite  relation  to  the  activity  and  extent  of  the  pulmonars'  dis- 
ease, this  is  not  always  true,  being  apparently  dependent  upon  the 
location  of  the  lesion  in  regard  to  the  bronchi  and  the  character 
of  the  process.  In  cases  in  which  the  signs  and  symptoms  point 
toward  an  arrest  of  the  tuberculous  disease,  the  cough  and  expec- 
toration may  persist.  This  may  be  due  to  the  presence  of  a 
cavity,  or  to  the  fact  that  the  fibrosis  resulting  from  the  heal- 
ing has  led  to  deformities  in  the  bronchi,  or  to  an  interference 
with  their  blood-supply,  resulting  in  a  chronic  hyperemia  or 
inflammation  of  the  bronchial  mucosa. 

Sputum.  The  microscopic  examination  of  the  sputum  may 
supply  information  of  the  greatest  diagnostic  significance.  The 
most  important  constituents  of  the  sputum,  to  be  sought  for  are 
the  tubercle  bacilli,  which  are  most  conveniently  demonstrated  by 
the  Ziehl-Xeelsen-Gabbett  method.  When  the  micro-organisms 
cannot  be  demonstrated  by  the  ordinar}^  technic.  it  is  advisable 
to  employ  the  antiformin  method  of  dissolving  and  centrifugating 
the  sputum,  for  the  tubercle  bacilli  may  frequently  be  demon- 
strated by  this  method.    It  has  the  advantage  of  concentrating  the 


PULMONARY    TUBERCULOSIS.  379 

tubercle  bacilli,  so  as  to  permit  of  examining  a  large  quantity  of 
sputum  on  one  or  two  slides.  When  it  is  imperative  that  a  posi- 
tive diagnosis  be  made,  it  may  be  necessary  to  resort  to  inocula- 
tion of  the  sputum  into  guinea-pigs,  a  procedure  which  has  certain 
disadvantages,  but  makes  the  diagnosis  absolutely  certain  when 
the  findings  are  positive. 

The  finding  of  tubercle  bacilli  in  the  sputum  makes  a  diagnosis 
of  tuberculosis  unquestionable,  but  unfortunately  the  absence  of 
tubercles  does  not  exclude  such  a  diagnosis.  A  negative  sputum 
examination  has  practically  no  significance,  in  so  far  as  excluding 
tuberculosis  is  concerned.  Even  repeated  negative  examinations 
must  not  be  accepted  as  conclusive;  evidence  that  tuberculosis  is 
not  present.  In  many  cases,  even  where  the  disease  is  of  consider- 
able extent,  tubercle  bacilli  have  been  demonstrated  in  the  sputum 
only  after  repeated  examinations,  and  in  a  small  group  of  cases 
in  which  the  diagnosis  of  tuberculosis  is  fully  justified  by  the 
clinical  findings,  it  may  be  impossible  to  detect  tubercle  bacilli  in 
the  sputum.  In  the  presence  of  symptoms  and  signs  indicating 
the  presence  of  pulmonary'  tuberculosis  one  should  never  delay 
making  a  positive  diagnosis  on  account  of  the  absence  of  tubercle 
bacilli.  When  they  can  be  identified  the  case  is  no  longer  an 
incipient  one,  and  the  chances  for  recovery  are  commeuisurately 
minimized.  Many  cases  have  lost  their  opportunity  of  getting 
well  through  the  disinclination  of  their  physician  tO'  make  a  posi- 
tive diagnosis  until  tubercle  bacilli  could  be  found. 

Elastic  fibres  may  be  found  in  the  sputum,  in  a  large  propor- 
tion of  tuberculous  cases,  and  while  they  do'  not  possess  the  same 
diagnostic  value  they  held  previous  to  the  discovery  of  the  tuber- 
cle bacillus,  their  presence  is  of  coinsiderable  value  in  doubtful 
cases  (see  Pulmonary  Abscess).  The  albumin  reaction  occurs  in 
the  sputum  in  numerous  diseases,  and,  therefore,  its  main  value 
lies  in  excluding  tuberculosis  when  repeated  tests  have  proven 
negative. 

Fever.  In  the  early  diagnosis  oi  tuberculosis  a  careful  record 
of  the  temperature  (see  Rest  and  Exercise)  is  of  the  greatest 
possible  help.  The  temperature  in  children  is  so  variable  that 
much  weight  cannot  be  attached  to  daily  variations  of  considera- 
ble extent,  but  in  adults  an  afternoon  rise  to  99°  F.  (37.4°  C.)  or 
more  must  be  considered  extremely  suggestive,  in  the  absence  of 
any  obvious  cause  for  such  an  elevation.     A  frankly  subnormal 


380  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

temperature  in  the  morning  on  rising  is  frequently  associated  with 
the  afternoon  rise,  which  gives  a  daily  variation  of  considerable 
extent.  In  cases  presenting  physical  signs  indicative  of  apical 
infiltration  of  the  lung  a  temperature  record  of  a  week  or  two  will 
frequently  be  of  value  in  determining  the  activity  of  the  process, 
and  should  always  be  insisted  upon  in  doubtful  cases.  Apparently 
the  tuberculous  individual  is  extremely  susceptible  to  factors 
responsible  for  an  elevation  of  temperature  in  the  healthy,  such 
as  exercise,  menstruation,  nen^ous  excitement,  and  so  forth.  The 
temperature  attributed  to  such  conditions  in  the  tuberculous  is 
usually  higher  and  more  prolonged  than  in  the  well,  in  whom  it  is 
usually  slight  and  evanescent.  When  moderate  exercise  induces  a 
distinct  rise  of  temperature,  persisting  at  the  end  of  one  hour's 
rest,  or  when  in  a  female  tliere  is  a  decided  premenstrual  or  men- 
strual fever,  tuberculosis  should  be  strongly  suspected.  When 
accompanied  by  other  symptoms  which  point  toward  pulmonar}'- 
tuberculosis  one  would  be  warranted  in  making  a  positive  diag- 
nosis, even  in  the  absence  of  definite  physical  signs,  when  no 
other  cause  for  the  rise  of  temperature  could  be  detected. 

Night-sweats.  Night-sweats  may  occur  early  in  the  disease, 
although,  as  a  rule,  they  are  more  frequently  encountered  and 
more  severe  in  the  advanced  stages.  For  many  years  they  have 
been  considered  as  pathognomonic,  and  while  they  undoubtedly 
occur  in  conditions  other  than  tuberculosis,  their  presence  in 
association  with  other  symptoms  of  tuberculosis  possesses  con- 
siderable value. 

Hoarseness.  Hoarseness  provoked  by  changes  in  the  weather, 
or  by  prolonged  use  of  the  voice,  is  frequently  an  early  symptom. 
Even  a  constant  sievere  hoarseness  may  be  present  in  cases  in 
which  there  is  no  actual  laryngeal  tuberculosis.  Temporary 
attacks  of  hoarseness  may  follow  hard  coughing  spells,  being 
apparently  due  to  the  adhesion  of  small  particles  of  mucus  to 
the  larynx.  When  this  symptom  is  present  a  careful  study  of  tlie 
larynx  should  be  made,  in  order  that  the  presence  of  actual  dis- 
ease or  of  paralysis  may  be  detected  in  the  early  stages. 

Hemoptysis.  There  is  no  symptom  which  is  so  distressing  to 
the  patient,  and,  when  carefully^  studied,  is  of  so  much  value  in 
the  diagnosis  of  tuberculosis,  as  the  expectoration  of  blood. 
\Mien  it  can  be  definitely  determined  that  the  blood  is  coming 
from  the  lung,  the  casie  should  be  considered  one  of  pulmonary 


PULMONARY   TUBERCULOSIS.  381 

tuberculosis  until  it  can  be  proved  that  some  other  cause  of  hemo- 
ptysis exists.  In  the  event  of  a  frank  expectoration  of  blood,  too 
much  care  cannot  be  employed  in  ruling  out  hematemesis  and 
epistaxis.  Hemorrhages  from  the  throat  are  extremely  rare,  and 
when  they  occur  the  source  of  the  bleeding  may  be  detected  by  a 
careful  examination.  Among  the  causes  of  pulmonary  hemor- 
rhage by  far  the  most  common  is  pulmonary  tuberculosis,  other 
factors  being  cardiac  disease,  bronchiectasis,  syphilis  of  the  lung, 
malignant  disease,  gangrene,  trauma,  and  vascular  hypertension. 

While  blood-streaked  sputmii  is  a  frequent  sign  of  tuberculo- 
sis, too  much  weight  should  not  be  attached  to  its  occurrence,  as 
it  frequently  occurs  in  other  conditions.  Many  of  the  hemor- 
rhages in  tuberculous  women  occur  at  the  menstrual  period,  and 
for  this  reason  are  usually  called  vicarious  menstruation.  While 
admitting  the  possibility  that  vicarious  menstruation  may  be  mani- 
fested in  the  form  oi  a  pulmonary  hemorrhage  in  an  otherwise 
healthy  woman,  any  hemoptysis  occurring  at  the  menstrual  periods 
ishould  always  be  viewed  with  extreme  suspicion. 

Gastro-intestinal  Symptoms.  Symptoms  referable  to  the 
digestive  tract  are  extremely  common  in  early  cases  of  pulmonary 
tuberculosis,  preceding  all  other  symptoms;  in  many  instances. 
The  appetite  is  variable,  and,  while  it  may  be  retained,  the 
majority  of  patients  show  some  disinclination  for  food.  The 
degree  of  anorexia  seems  to  bear  no  relation  to  the  height  of  the 
fever,  some  phthisics  retaining  their  appetite  in  the  face  of  con- 
siderable elevation  of  temperature.  An  aversion  to  fats  has  been 
noted  among  the  tuberculous  by  several  observers,  and  at  times 
thd  carbohydrates,  especially  the  saccharins,  are  the  foodstufifs  to 
which  an  aversion  arises..  The  gastric  disturbances  seen  in  early 
cases  are  in  no  way  characteristic,  the  symptoms  being  the  same 
as  those  associated  with  a  moderate  lack  of  gastric  motility  and 
diminisihed  secretion  due  to  any  other  cause. 

Loss  of  Weight.  Loss  O'f  weight  in  the  early  stages  of  tuber- 
culosis is  almost  invariable,  being  frequently  the  symptom  which 
has  first  attracted  the  attention  of  the  patient  to  the  possibility  of 
this  disease.  The  loss  of  weight  is  not  attributable  solely  to  the 
digestive  disturbances,  since  it  may  occur  in  those  whose  diges- 
tion is  unimpaired.  Progressive  loss  of  weight  in  anyone  should 
suggest  the  possibility  oi  tuberculosis,  especially  wdien  associated 
with  other  symptoms  pointing  in  the  same  direction.     Cases  are 


382  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

encountered  in  which  the  subject  is  not  emaciated,  but,  on  the 
contrary,  extremely  well  nourished,  and  the  presence  of  a  thick 
deposit  of  subcutaneous  fat  does  not  exclude  pulmonarv^  tubercu- 
losis. 

Cardiovascular  System.  Cardiac  palpitation,  tachycardia,  and 
hypotension  are  the  most  important  functional  disturbances  of 
the  cardio-vascular  system  encountered  in  pulmonar}^  tuberculosis. 
The  attacks  of  cardiac  palpitation  may  follow  upon  the  slightest 
exertion  or  excitement,  and  occasionally  are  extremely  severe  and 
distressing.  Rapidity  of  the  cardiac  action  is  almost  constant  in 
all  Sitag-es  of  the  disease,  and  may  possess  considerable  diagnostic 
importance.  While  a  rapid  pulse  usually  accompanies  the  febrile 
manifestations  of  pulmonary'  'tuberculosis,  this  evidence  of  tox- 
emia may  precede  any  obvious  elevation  of  temperature,  and  may 
persist  after  the  temperature  has  become  normal.  The  study  of 
the  pulse-rate  in  tuberculosis  is  important,  not  only  from  the 
standpoint  of  diagnosis,  but  because  it  is  also  a  valuable  guide  in 
the  treatment  of  the  disease.  In  a  few  instances  an  abnormally 
slow  pulse  has  been  observed  in  this  disease,  but  the  occurrence 
of  bradycardia  must  be  so  rare  as  to  be  practically  negligible. 

A  certain  proportion  of  those  suffering  from  pulmonary  tuber- 
culosis has  been  repeatedly  shown  to  have  a  heart  of  smaller  size 
than  normal,  whether  due  to  hypoplasia  or  to  atrophy  and  degen- 
eration of  the  cardiac  substance.  Certain  writers  have  attempted 
to  prove  that  the  small  heart  bears  a  predisposing  relation  to  the 
pulmonary  disease,  but  it  is  doubtful  whether  the  small  size  of 
the  heart  can  be  considered  as  directly  predisposing  to  tuberculo- 
sis of  the  lungs. 

The  blood-pressure  is  almost  always  low  in  individuals  suffer- 
ing from  tuberculosis,  this  peculiarity  being  so  universally  true 
that  the  presence  of  arterial  hypotension  should  always  suggest 
the  probability  of  this  diagnosis. 

Anemia.  The  majority  of  patients  present  the  appearance  of 
anemia,  but  this  suggestion  is  not  always,  borne  out  by  the  exami- 
nation of  the  blood.  A  diminution  in  the  number  of  erythrocytes 
is  uncommon,  although  the  presence  of  a  chloroanemia  is  rela- 
tively frequent,  the  blood-picture  being  characterized  by  a  distinct 
and  predominant  loss  of  hemoglobin.  In  the  moderately  advanced 
cases  it  is  not  unusual  to  find  a  polycythemia,  with  a  low  color 
index.  The  leucocyte  changes  are  hardly  constant  enough  to  be 
of  value,  from  the  standpoint  of  diagnosis. 


PULMONARY    TUBERCULOSIS.  383 

Nervous  Phenomena.  The  vaguely  defined  group  of  symp- 
toms termed  neurasthenia  are  frequently  encountered  even  in  the 
early  stages  of  pulmonary  tuherculosis.  Various  reflex  nervous 
phenomena  are  not  uncommon,  and  such  isymptoms  result  from 
disturbances  of  the  sympathetic  system,  and  are  manifested 
chiefly  by  localized  flushing  and  sweating  and  dilatation  of  the 
pupils.  Pains  in  the  chest  are  frequently  present,  but  they  seem 
to  bear  no  definite  relation  to  the  location  or  character  of  the  pul- 
monary lesion,  and  are  reflex  in  origin  in,  the  majority  of  cases. 

Physical  Signs.  From  the  history  and  symptomatology  in 
probably  a  large  proportion  of  cases  it  is  possible  to  reach  a 
fairly  reliable  conclusion  as  to  the  probable  existence  of  pul- 
monary tuberculosis  in  the  individual  case,  the  physical  exami- 
nation of  the  patient  being  employed  merely  as  a  means  of 
confirming  such  an  opinion.  In  the  v^ell-marked  or  moder- 
ately advanced  examples  of  the  infection,  the  facial  expression 
and  the  general  appearance  of  the  suspect  may  unconsciously 
influence  the  examining  physician  in  formulating  his  tentative 
diagnosis.  In  arriving  at  a  positive  diagnosis,  giving  a  prog- 
nosis, or  outlining  treatment,  it  is  essential  that  a  physical 
examination  of  the  patient  be  carefully  made.  It  is  not  the 
intention  to  describe  in  detail  all  the  physical  signs  found  in 
pulmonary  tuberculosis,  but  merely  to  call  attention  to  the 
signs  which  seem  to  be  of  most  value  or  are  usually  neglected. 
Before  taking  up  the  various  signs,  and  the  methods  by  which 
they  may  be  elicited,  it  may  be  worth  while  calling  attention 
to  the  fact  that  there  are  no  pathognomonic  signs  of  pulmon- 
ary tuberculosis.  'For  a  diagnosis,  then,  it  is  merely  necessary 
to  discover  evidence  of  disease  of  the  lung,  usually  in  the  form 
of  an  infiltration,  which  is  confined  to  or  is  most  marked  at  the 
apex  of  one  or  both  lungs,  and  occurring  in  a  person  who  pre- 
sents the  appearance  and  symptoms  of  tuberculosis. 

Inspection  and  palpation  of  the  thorax  are  indispensable 
details  of  a  complete  physical  examination.  There  are  certain 
facial  characteristics  which  are  extremely  suggestive  of  pul- 
monary tuberculosis,  especially  when  it  is  of  long  standing-, 
but  it  should  be  borne  in  mind  that  this  aft'ection  may  occur  in 
those  who  present  the  picture  of  perfect  health.  Atrophy  of 
the  facial  muscles  with  prominent  malar  bones,  pallid  lips, 
flushed   cheeks,  the   long  thin   neck,   and   stooped   shoulders, 


384  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

together  form  a  characteristic  picture  of  the  confirmed  con- 
sumptive. The  appearance  of  the  eye  is  probably  the  most 
striking  and  typical  feature  of  the  face,  this  change  being  due 
to  the  dilated  pupil  with  the  pearly  white  sclerotic,  giving  it 
a  peculiar  transparent  brilliancy,  accentuated  by  being  deeply 
set  in  the  socket.  The  hands  also  frequently  show  character- 
istic changes,  the  skin  being  dusky  or  pale,  and  the  nails  fre- 
quently curved,  with  or  without  clubbing  of  the  ends  of  the 
fingers. 

Inspection  of  the  chest,  which  should  always  be  made  with 
at  least  the  upper  half  of  the  thorax  exposed,  usually  gives 
information  of  enormous  value.  JMen  should  be  stripped  to 
the  waist  for  a  satisfactory  examination;  and  too  much 
emphasis  cannot  be  laid  upon  the  importance  of  removing  the 
clothing  when  examining  the  chest.  The  exposure  is  objec- 
tionable to  women,  and  can  be  avoided,  without  seriously 
interfering  with  the  examination,  by  having  them  remove  the 
corsets  and  lower  the  clothing  to  the  waist-line,  the  chest 
being  covered  by  a  light  flannel  shawl  or  a  thin  kimono-shaped 
jacket  fastened  in  front  and  back  with  a  few  buttons  or  tapes. 
By  having  the  jacket  large  and  full,  it  may  be  slipped  down 
in  front  or  in  back  as  desired,  only  that  portion  of  the  chest 
which    is    under    examination    being    exposed    at    the    time. 

Pityriasis  versicolor  of  the  skin  of  the  chest,  and  dilated 
venules  or  enlarged  veins  below  the  clavicles,  posteriorly  in 
the  region  of  the  upper  thoracic  spines,  or  along  the  lower 
costal  margin,  are  frequently  met  with  in  phthisis.  A  great 
deal  of  stress  has  been  laid  upon  the  significance  of  the 
phthisical  chest,  but  pulmonary  tuberculosis  may  occur  in 
chests  of  any  type,  shape,  or  size.  It  is  a  mistake  to  attach 
too  much  importance  to  the  general  configuration  of  the  chest 
in  its  relation  to  the  diagnosis  of  this  disease.  Much  more 
important  is  the  detection  of  differences  between  the  two 
sides  of  the  chest,  whether  of  contour  or  mobility.  Depres- 
sions above  and  below  the  clavicles  are  of  considerable  impor- 
tance, especially  when  more  marked  on  one  side  or  the  other. 
The  flattening  of  the  ribs  over  one  apex  or  the  other  may  fre- 
quently be  visible,  but  this  is  always  better  elicited  by  the 
hand  placed  over  the  upper  chest  with  the  fingers  pointing 
toward  the  coracoid  process. 


PULMONARY    TUBERCULOSIS. 


385 


The  flattening  of  the  ribs  and  the  loss  of  the  natural  ante- 
rior curve  can  be  easily  felt  with  the  hand  in  tliis  position, 
usually  confined  to  one  apex.  Diminished  expansion  over  the 
upper  portion  of  one  lung  may  be  observed,  or,  more  com- 
monly, the  upper  chest  on  the  affected  side  is  seen  to  lag 
behind  the  other,  even  when  the  expansion  of  both  sides  is 
equal.     This  is  seen  to  better  advantage  by  standing  in  back 


Fig.  7. — Pulmonary  tuberculosis  (right-sided).  Note  the 
long,  narrow  chest,  and  the  marked  depression  above  and  below 
the  right  clavicle. 


of  the  patient,  but  it  can  be  elicited  best  by  palpation,  espe- 
cially when  it  is  possible  to  seize  the  upper  portions  of  both 
halves  of  the  chest  between  the  fingers  and  thumbs.  Standing 
behind  the  patient  with  the  thumbs  posteriorly  along  the 
upper  and  inner  edge  of  the  scapulse,  the  elbows  elevated,  and 
the  palmar  surface  of  the  fingers  pressed  against  the  upper 
portion  of  the  anterior  chest,  it  is  much  easier  to  detect  slight 


386 


DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


differences  of  expansion  on  the  two  sides,  or  lagging  at  one 
apex  on  the  other.  This  lagging  is  frequently  present  very 
early  in  the  disease  and  is  of  special  value  in  unilateral  cases. 
The  flattening  and  lack  of  expansion  at  one  apex  practically 
always  indicates  either  long-standing  fibroid  change  or  exten- 
sive infiltration  and  considerable  loss  of  tissue  from  cavity 
formation.  When  the  symptoms  and  signs  suggest  an  early 
lesion  in  a  subject  with  signs  of  retraction  and  loss  of  expan- 


Fig.  8. — Illustrating  method  of  palpating  apices  to  determine  their 
relative  expansibility. 


sion  at  one  apex,  it  ma}^  be  taken  as  evidence  that  the  present 
illness  is  a  reinfection  or  an  acute  exacerbation  of  an  old 
fibroid  process.  Differences  in  the  expansibility  of  the  lower 
portions  of  the  chest  can  be  best  brought  out  by  standing  in 
back  of  the  patient  and  grasping  the  chest  between  the 
fingers  and  thumbs,  with  the  thumbs  posteriorly,  by  com- 
paring the  excursion  of  the  thumbs  in  their  relation  to  the 
spine  (which  may  be  marked  with  a  blue  pencil)  during 
forced  respiration.     By  this  procedure  slight  differences  can 


PULMONAin'   TUP.ERCULOSTS. 


387 


be  detected  readily,  if  care  be  used  to  make  equal  pressure 
on  the  two  sides  of  the  chest.  The  hands  should  rest  as  lig-htly 
as  possible  ag;ainst  the  chest  wall,  undue  pressure  beinj:^ 
avoided,  as  only  sufficient  pressure  is  needed  to  maintain  the 


Fig.  9. — Method  of  palpating  lower  portion  of  chest  to  determine 
relative  expansibility  of  the  two  sides. 


hands  in  close  apposition  to  the  walls  of  the  chest.  The  dif- 
ference in  expansion  of  the  lower  chest  may  be  due  to  pleurisy, 
or  to  tuberculous  invasion  of  that  portion  of  the  lung  on  one 
or  the  other  side. 

In  addition  to  the  above  technical  methods,  inspection  and 
palpation  should  be  employed  to  locate  the  apex  beat  and  to 


388  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

detect  abnormalities  in  the  chest  or  abdomen  which  might 
have  any  possible  bearing  upon  tuberculosis  of  the  lungs. 
Where  there  is  considerable  retraction  of  the  left  lung,  for 
example,  whether  due  to  fibroid  changes  or  to  cavity  forma- 
tion, inspection  frequently  reveals  an  abnormal  degree  of  car- 
diac pulsation.  In  very  thin  persons  it  may  be  possible  to 
observe  almost  the  complete  cardiac  contraction  by  means  of 
the  pulsations  conveyed  to  the  chest  walls,  as  a  result  of  the 
retraction  of  that  portion  of  the  lung  which  normally  rests 
between  the  heart  and  the  anterior  wall  of  the  thorax. 

Disease  of  the  lung  is  believed  by  some  observers  to  be 
accompanied  b}^  changes  in  the  overlying  muscles,  active  dis- 
ease causing  spasmodic  contraction,  and  healed  lesions  giving 
rise  to  loss  of  elasticity  and  wasting.  It  would  seem  advis- 
able for  the  present  to  rely  upon  such  changes  in  the  sym- 
metrical structure  or  mobility  of  the  chest,  rather  than  upon 
these  somewhat  uncertain  trophic  muscular  phenomena. 

Mensuration  of  the  chest  is  used  chiefly  to  detect  the  asym- 
metry of  the  two  sides,  a  defect  clearly  demonstrable  in  many 
instances  by  charting  the  outline  of  the  thorax  by  means  of 
the  c3'rtometer  or  measuring  it  with  a  pelvimeter.  This 
method  has  the  advantage  of  recording  the  variations  in  the 
chest  wall  so  that  they  may  be  kept  for  future  reference. 
Various  elaborate  instruments  have  been  devised  for  accu- 
rately recording  the  outline  of  the  thoracic  wall,  but  the  use 
of  the  pelvimeter  and  the  lead  strip  is  much  less  expensive  and 
simpler,  giving  records  which  are  sufficiently  accurate  for  prac- 
tical purposes,  if  care  be  used  in  employing  them. 

The  tracing  for  recording  the  general  contour  of  the  chest 
should  be  made  preferably  at  the  level  which  will  just  avoid 
the  scapulae,  although  it  may  be  made  at  any  level  for  deter- 
mining asymmetr)^  The  sternal  attachment  of  the  fourth 
costal  cartilage  usually  gives  a  level  affording  a  definite  out- 
line of  the  chest  wall  not  distorted  by  the  scapulae.  The  cen- 
ter of  the  sternum  is  marked  by  a  small  cross  at  this  level,  and 
a  corresponding  point  on  the  spine  (usually  the  eighth  thor- 
acic spine)  is  determined  by  means  of  the  pelvimeter,  and  this 
point  also  marked  by  a  cross.  The  distance  between  these 
two  points  is  determined  by  reading  the  scale  on  the  pelvi- 
meter,   some    of   which    instruments    may    be    locked    at   the 


PULMONARY    TUBERCULOSIS. 


389 


desired  point  by  means  of  a  set-screw.  These  two  points  are 
marked  on  a  sheet  of  paper,  and  a  line  drawn  between  them. 
One  end  of  the  lead  strip  is  then  placed  at  the  posterior  mark 
and  moulded  as  closely  to  the  chest  as  possible,  workinjr  it 
against  the  chest  from  the  back  toward  the  front.  When  in 
close  apposition  the  tape  is  marked  where  it  crosses  the  ante- 


Fig.  10. 


.^--— 

^■^■- ~- 

■    / 

/- 

\ 

\ 

^' 

■^■ 

Pig.  11. 


Figs.   10  and   IL — Chest  tracings  of  two  patients  vv^ith  left-sided 
pulmonary  tuberculosis. 


rior  point,  and  carefully  lifted  away  from  the  chest  and  laid 
on  the  paper  with  the  anterior  and  posterior  points  of  the 
tape  corresponding  to  the  points  previously  marked  on  the 
paper.  A  tracing  is  then  made  with  a  soft  pencil,  care  being 
taken  not  to  distort  the  lead  strip,  which  should  be  held  firmly 
against  the  paper. 

It   will   be    found   that   the    point   of   greatest   transverse 
diameter  of  the  chest  as  measured  by  the  calipers  varies  from 


390 


DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


one-half  to  one  and  one-half  inches  (1.27  to  3.81  cm.)  shorter 
than  the  tracing  recorded  by  the  lead  strip.  This  is  due  to 
the  fact  that  the  points  of  the  calipers  can  be  pressed  more 
closely  to  the  ribs  than  with  the  cyrtometer,  especially  when 
there  is  considerable  subcutaneous  fat.     It  is  well  to  record 


Fig.    12. — Showing  method   of   applying  lead   tape   cyrtometer   to 
obtain  chest  tracing. 


on  the  tracing  the  actual  transverse  diameter  as  measured 
by  the  calipers,  indicating  it  by  a  line  at  right  angles  to  the 
antero-posterior  line  at  the  level  of  the  greatest  transverse 
diameter,  shown  on  the  tracing. 

Percussion.  There  is  considerable  difference  of  opinion  as  to 
whether  percussion  or  auscultation  reveals  the  earliest  evidence 
of  tuberculous  infiltration  of  the  lungs.    Early  consolidation  of 


PULMONARY    TUBERCULOSIS. 


391 


the  lungs  is  manifested  by  various  signs  in  ditlerent  cases, 
depending  upon  the  character  and  location  of  the  tuberculous 
process.  For  this  reason  it  is  impossible  to  state  which 
method  of  examination  is  the  more  valuable,  as  either  method 
may  first  reveal  the  disease  under  varying  circumstances. 

To  be  of  any  value,  percussion  must  be  performed  cor- 
rectly, the  blows  of  the  percussing  finger  being  made  upon  the 


Fig.  13. — Showing  method  of  employing  pelvimeter  for  obtain- 
ing antero-posterior  diameter  of  chest  in  taking  tracing  of  the 
chest  outline. 

finger  closely  applied  to  the  chest  wall,  only  such  force  being 
used  as  will  elicit  an  audible  sound.  Heavy  percussion  is  not 
only  valueless  but  misleading,  and  the  method  of  using  two 
or  three  fingers  is  to  be  especially  condemned.  The  plexi- 
meter  finger  should  be  rested  evenly  in  the  interspace  to  be 
percussed,  but  strong  pressure  should  be  avoided.  The  middle 
finger  should  be  used  for  the  plexor,  the  two  distal  phalanges 
being  bent  at  right  angles,  and  the  blows  being  made  from 


392  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

the  wrist  or  by  the  finger  alone,  the  movement  being  made  at 
the  metacarpophalangeal  joint.  The  plexor  should  not  be 
allowed  to  press  against  the  pleximeter  finger  after  striking 
the  blow,  but  should  be  quickly  removed,  and  too  many  blows 
at  one  point  should  be  avoided.  One  or  two  sharp,  quick 
blows  should  be  sufficient  to  bring  out  the  sound.  Slight  im- 
pairment of  resonance  at  the  apices  can  be  best  elicited  by 
percussing  the  chest  from  below  upward,  each  interspace 
being  compared  with  the  corresponding  point  on  the  opposite 
side.  A  study  of  the  apices  by  means  of  Kronig's  resonant 
areas  is  frequently  of  value,  slight  infiltration  at  one  apex 
being  revealed  by  contraction  of  the  isthmus  on  the  side 
afi:ected,  or  by  what  is  equally  significant,  an  obscuring  of  the 
dividinof  line  between  resonance  and  dullness,  which  is  sharply 
defined  in  the  healthy  apex.  To  demarcate  these  zones  of 
resonance  at  the  apex  very  light  percussion  is  necessary,  the 
pleximeter  finger  being  applied  to  the  apex  in  a  position  at 
right  angles  to  the  clavicle.     (Fig.  14.) 

In  percussing  the  chest  it  is  important  that  the  patient  sit 
or  stand  in  an  easy  position,  the  head  held  in  the  natural 
antero-posterior  position,  with  the  muscles  of  the  neck  and 
chest  as  relaxed  as  possible.  In  percussing  the  apices  it  is 
frequently  found  to  be  easier  if  the  examining  physician  stand 
at  the  side  of  the  patient  or  even  posteriorly,  in  order  to  get 
the  pleximeter  finger  in  close  apposition  to  the  skin  in  the 
supraclavicular  fossse.  For  examining  the  back  of  the  chest 
the  patient  should  sit  with  the  arms  folded,  the  body  bending 
slightly  forward,  with  the  shoulders  relaxed  and  drooped.  It 
is  impossible  to  examine  the  upper  portions  of  the  lung  pos- 
teriorly with  the  shoulders  held  rigidly  erect.  For  examining 
the  posterior  portions  of  the  lung  the  scapulse  should  be  pulled 
as  far  forward  as  possible  in  order  to  expose  the  posterior 
chest  wall.  To  secure  this  it  may  be  necessary  to  have  the 
arms  crossed  in  front  with  the  hands  resting  well  over  the 
opposite  shoulder.  This  position  should  never  be  assumed 
for  the  examination  of  the  apices. 

The  most  important  evidence  of  early  infiltration  elicited 
by  percussion  is  impairment  of  resonance,  but  a  diagnosis  of 
tuberculous  disease  should  never  be  based  on  this  finding 
alone.     It  must  be  considered  only  as  a  part  of  the  general 


PULMONARY   TUBERCULOSIS. 


393 


clinical  picture.  Hyper-resonance  or  tympany  (Skodaic) 
occasionally  is  present  where  the  disease  is  incipient,  slight, 
and  composed  of  scattered  tubercles.  When  there  is  a  distinct 
difference  between  the  percussion  sounds  at  the  two  apices,  it 
is  necessary  in  certain  cases  to  differentiate  between  an  im- 
pairment of  resonance  at  one  apex  or  a  hyper-resonance  at  the 
other.     While  this  may  ha  difficult,  it  usually  may  be  deter- 


Fig.   14. — Kronig's  isthmus  in  a  patient  with  an  old  tuberculous 
process  at  the  top  of  the  left  lung. 

mined   by   comparing   the   sound   obtained   at  the   apex   with 
that  elicited  over  the  lower  portions  of  the  chest. 

There  are  numerous  sources  of  error  in  interpreting  signs 
at  the  apices  by  percussion.  These  may  be  due  to  faulty 
technic ;  distortion  of  the  chest  by  spinal  curvature ;  inequality 
of  muscular  development;  lack  of  knowledge  of  the  normal 
size  and  location  of  the  lung;  or  the  normal  dift'erence  between 
the  sounds  at  the  two  apices.  In  addition  to  these  potential 
sources  of  error,  it  must  be  remembered  that  impairment  of 


394  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

resonance  results  from  a  decrease  in  the  amount  of  air-bearing 
tissue,  and  that  this  may  be  due  to  contraction  of  the  apex 
as  the  result  of  scarring  from  a  healed  process,  or  probably 
from  collapse  induration  as  a  result  of  dust  inhalation  in  mouth- 
breathers.  In  persons  who  lead  sedentary  lives  the  percussion 
sound  at  the  apices  is  practically  never  so  resonant  as  in  those 
whose  daily  life  callsl  for  exercises  demanding  deep  breathing. 

In  the  later  stages  of  the  disease  percussion  is  of  the  great- 
est possible  value  in  determining  the  extent  and  density  of  the 
infiltration,  the  presence  of  cavities,  and  the  development  of 
pleural  complications,  such  as  effusion  and  pneumothorax. 

Auscultation,  when  properly  performed,  is  a  method  of  ex- 
amination invaluable  in  detecting  early  infiltration,  and  in 
determining  the  character  of  the  pulmonary  process. 

Before  listening  to  the  chest  the  patient  should  be  instruc- 
ted to  breathe  slowly,  and  slightly  deeper  than  normal,  with 
the  mouth  open.  The  respiratory  movements  should  be  easy, 
without  undue  muscular  eft'ort,  and  the  movements  should  not 
be  suspended  at  the  end  of  inspiration  or  expiration,  but  an 
efifort  should  be  made  to  follow  the  natural  rhythm.  The 
examination  should  always  be  made  in  a  room  comfortably 
warm,  for  the  least  shivering  of  the  patient  may  give  rise  to 
confusing  sounds.  The  type  of  the  binaural  stethoscope  to 
employ  depends  upon  the  personal  preference,  but  in  the  major- 
ity of  instances  the  instruments  with  a  small  hollow  bell, 
without  a  diaphragm,  will  be  found  most  satisfactory.  Care 
must  be  used  to  see  that  the  opening  of  the  bell  is  held  eventy 
and  firmly  against  the  chest,  inasmuch  as  the  slightest  move- 
ment of  the  instrument  on  the  chest  wall  may  provoke  very 
misleading  sounds. 

For  a  proper  appreciation  of  the  various  changes  in  the 
breath-sounds,  it  is  absolutely  essential  that  the  observer  be 
thoroughl}-  familiar  with  the  normal  respiratory  murmur,  and 
that  he  listens  to  the  chest  at  every  opportunity.  It  is  impos- 
sible for  the  average  physician  to  detect  slight  changes  unless 
he  is  accustomed  to  listening  to  the  breath-sounds  almost 
daily. 

The  changes  which  occur  in  the  breath-sounds  in  early 
tuberculous  disease  of  the  lungs  are  not  pathognomonic,  and 
must  be  considered  onlv  in  their  relation  to  the  apex  and  in 


PULMONARY   TUBERCULOSIS.  395 

relation  with  the  other  signs  and  symptoms.  Healed  lesions 
at  the  apex  may  give  signs  indicative  of  actual  tuberculous 
disease,  the  true  condition  only  being  determined  in  some 
cases  by  other  measures  for  estimating  the  presence  of  active 
disease,  such  as  a  study  of  the  temperature  and  pulse. 

The  types  of  breathing-  suggestive  of  the  presence  of  pul- 
monary tuberculosis  are :  feeble  breathing,  granular  breath- 
ing, cog-wheel  breathing,  bronchovesicular,  and  bronchial 
breathing. 

In  the  earliest  cases  met  with  clinically  the  first  two 
mentioned  are  the  types  most  frequently  encountered.  When 
the  two  last-named  types  are  present,  the  condition  can 
hardly  be  considered  as  an  early  lesion.  Feeble  breathing  is 
only  of  value  when  localized  over  one  apex  and  uninfluenced 
by  deep  respiration  or  by  coughing.  At  times  the  breath- 
sounds  may  be  absent.  The  breath-sounds  are  of  a  character 
which  might  be  more  correctly  termed  ."indefinite"  rather  than 
by  the  name  "feeble."  True  feeble  breathing  must  not  be  con- 
fused with  the  areas  of  feeble  or  absent  breath-sounds  occa- 
sionally audible  in  patients  in  which  the  bronchi  contain  large 
quantities  of  secretion,  and  in  whom  the  breath-sounds  are 
again  heard  after  coughing.  Granular  breathing  is  character- 
ized by  a  fine,  dry,  sputtering  quality  of  the  breath-sounds 
which  has  been  described  as  resembling  the  sounds  of  frying 
fat  or  as  though  soft  granules  of  fine  wet  sago  were  being 
rolled  over  each  other.  It  always  suggests  the  addition  of  fine 
dry  rales  to  the  breath-sounds.  While  some  observers  believe 
that  this  type  of  breathing  occurs  only  in  the  presence  of  early, 
active  disease,  others  believe  that  it  may  occur  in  healed  tuber- 
culosis. While  admitting  the  possibility  of  granular  breathing 
in  the  presence  of  a  healed  lesion,  its  occurrence  at  one  apex 
usually  indicates  active,  recent  pulmonary  tuberculosis. 

Formerly  considerable  weight  was  attached  to  the  occur- 
rence of  cog-wheel  breathing.  AVhen  confined  to  one  apex  it 
may  indicate  the  presence  of  a  lesion,  but  is  an  uncommon 
finding  in  early  tuberculosis  of  the  lungs.  This  type  is  com- 
monly met  with  in  nervous  individuals,  especially  women,  in 
which  case  it  is  heard  over  the  greater  portion  of  the  chest. 
Cog-wheel  breathing  may  also  be  heard  during  an  attack  of 
acute  pleurisy. 


396  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

Prolongation  of  the  expiration  alone  rarely  may  occur  over 
an  area  of  infiltration,  but  when  present  it  is  usually  elevated 
in  pitch,  and  has  more  or  less  the  character  of  the  broncho- 
vesicular  type  of  breathing-. 

Pure  bronchial  or  tubular  breathing  is  heard  in  its  most 
typical  form  in  absolute,  superficial  consolidation  of  the  lung. 
This  is  rarely  met  with  in  pulmonary  tuberculosis,  except  in 
acute  tuberculous  pneumonia  or  in  the  scattered  areas  of  the 
rapidly  spreading  broncho-pneumonic  type.  It  is  more  com- 
monly found  in  association  with  vesicular  breathing,  consti- 
tuting broncho-vesicular  breathing,  the  extent  to  which  the 
bronchial  element  predominates  being  dependent  upon  the 
density  of  the  underlying  infiltration  and  its  proximity  to  the 
surface. 

Information  of  considerable  value  in  determining  the  pres- 
ence of  abnormalities  may  be  obtained,  according  to  some 
observers,  by  comparing  bilaterally  the  inspiratory  or  expira- 
tory phases  of  the  respiratory  murmur.  In  this  method  of 
study  the  stethoscope  is  applied  to  the  chest  only  during 
inspiration,  for  example,  removed  from  the  chest  at  the  end 
of  inspiration,  and  then  applied  to  the  corresponding  point  on 
the  opposite  side  during  the  corresponding  phase  of  respira- 
tion. By  this  means  it  is  believed  that  slight  differences  on  the 
two  sides  are  more  easily  recognized  than  when  one  com- 
pares the  entire  respiratory  murmur.  It  appears  to  the  writer 
that  the  moving-  from  one  side  to  the  other  would  tend  to  dis- 
tract  the  examiner,  and  to  prevent  that  concentration  upon  the 
breath-sounds  which  is  so  necessary  if  one  is  to  obtain  all  the 
information  possible. 

When  listening  to  the  breath-sounds  in  the  chest,  all  dis- 
tracting noises  and  movements  should  be  eliminated,  the 
examiner  training  himself  to  concentrate  the  attention  upon 
the  breath-sounds  alone,  disregarding  all  adventitious  sounds 
arising  within  the  chest. 

Rales  are  extremely  valuable  aids  in  the  diagnosis  of  tuber- 
culosis when  their  significance  is  fully  appreciated.  They  are 
one  of  the  signs  which  are  liable  to  vary  from  day  to  day,  and 
for  this  reason  are  of  value  in  estimating  the  progress  of  a  case 
under  observation.  They  are  very  variable,  however,  and  too 
rauch  reliance  must  not  be  placed  upon  their  increase  or  de- 


PULMONARY    TUBERCULOSIS.  397 

crease,  unless  repeated  examinations  have  demonstrated  that 
the  change  is  permanent. 

Many  cases  are  encountered  in  which  no  rales  are  evident 
on  examination  by  the  usual  methods,  the  adventitious  sounds 
becoming-  apparent  only  after  coughing.  It  is  always  a  good 
rule,  in  examining  for  pulmonary  tuberculosis,  after  com- 
pleting the  regular  exainination,  to  go  over  the  apices  care- 
fully again,  after  having  the  patient  give  a  slight  cough  imme- 
diately followed  by  a  deep  inspirationi.  By  this  method  small 
areas  of  fine  rales  may  be  discovered  which  would  otherwise 
escape  notice,  especially  in  the  "danger  zone"  along  the  inter- 
nal border  of  the  scapulae  at  about  the  level  of  the  spine  of 
the  scapula.  Properly  to  expose  this  area,  it  is  necessary  to 
throw  the  scapula  as  far  outward  and  forward  as  possible,  by 
placing  the  arm  far  across  the  anterior  chest,  the  hand  resting 
well  over  the  opposite  shoulder. 

Generalized  rales  have  very  little  significance  from  the 
standpoint  of  tuberculosis,  for  it  is  only  when  they  are  local- 
ized to  one  or  both  apices  that  they  are  of  value. 

The  information  to  be  obtained  from  a  study  of  the  rales, 
in  addition  to  the  knowledge  derived  from  the  fact  that  they 
are  localized  to  the  apex  or  most  marked  in  that  region,  con- 
sists in  the  size  of  the  bronchi  involved  as  indicated  by  size 
of  the  rales,  and  in  some  instances  the  degree  of  infiltration  of 
the  intervening  lung  tissue  may  be  estimated  from  their  char- 
acter. That  the  finest  bronchioles  or  alveoli  themselves  are 
implicated  is  usually  indicated  when  crepitant  rales  are  pres- 
ent, moisture  in  the  bronchioles  giving  fine,  moist  rales,  and 
in  the  larger  bronchi  rales  of  a  larger  size.  The  sibilant  and 
sonorous  rales  do  not  have  the  same  significance  as  the  moist 
rales,  as  they  are  due  either  to  simple  swelling  of  the  mucosa 
or  to  constriction  of  the  bronchial  lumen.  Cavities  are  usually 
accompanied  by  bubbling  rales — suggesting  a  space  larger 
than  any  bronchus  normally  present  at  the  point  of  examina- 
tion. The  point  must  always  be  borne  in  mind  that  rales  of  a 
certain  size  might  indicate  the  presence  of  a  cavity  if  heard 
over  one  portion  of  the  lung,  and  not  when  heard  over  another 
portion,  depending  upon  the  size  of  the  bronchi  which  should 
be  present  normally  in  that  location.  When  a  cavity  exists 
the  rales  may  indicate  that  fact  by  their  amphoric  quality. 


398  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Rales  occurring  in  bronchi  surrounded  by  a  zone  of  consolida- 
tion or  dense  infiltration  are,  as  a  rule,  most  metallic  and 
resonant,  being  loud  and  distinctly  transmitted  to  the  chest 
wall.  The  quality  of  the  rales  is  especially  important  in  deter- 
mining the  extent  of  the  infiltration  in  those  cases  in  which 
the  rales  are  so  numerous  as  to  obscure  the  breath-sounds. 

It  will  be  seen  that  the  presence  of  rales  may  convey  a 
great  deal  of  valuable  information,  not  only  in  the  early  stages 
of  the  disease,  but  also  in  determining  the  location  and  char- 
acter of  the  infiltration,  and  as  an  indication  of  the  progress 
of  a  case  under  treatment. 

Vocal  resonance  is  not  of  a  great  deal  of  value  in  early  pul- 
monary tuberculosis,  and  only  in  rare  instances  will  it  supply 
information  which  cannot  be  more  accurately  obtained  by 
other  methods  of  examination.  The  transmission  of  the 
whispered  voice  is  much  more  valuable,  especially  for  localiz- 
ing areas  of  consolidation  or  cavities.  The  whispering  pec- 
toriloquy heard  over  cavities  usually  possesses  a.  more  am- 
phoric or  cavernous  quality  than  that  due  to  a  consolidation,, 
which  is  usually  more  distinct  and  tubular.  When  the  con- 
solidation is  near  the  surface,  the  whispered  voice  is  beauti- 
fully clear  and  sharp,  the  words  being  distinctly  transmitted  to 
the  examining  ear,  and  one  is  impressed  with  not  merely  the 
sense  of  articulate  speech,  such  as  commonly  accompanies 
deeper  consolidations  or  cavities. 

The  early  diagnosis  of  tuberculosis  by  means  of  the  Ront- 
gen  ray  has  proved  very  disappointing,  as  it  was  hoped  that 
by  this  means  it  would  be  possible  to  detect  lesions  in  the 
lungs  in  the  earliest  stages.  The  more  advanced  the  lesion, 
the  more  distinctly  is  it  recorded  upon  the  plates,  but  it  is 
impossible  to  ascertain  by  this  method  an  accurate  idea  of 
the  activity  of  the  process.  The  main  value  of  skiagraphy  is 
to  confirm  the  results  of  physical  examination  in  localizing 
the  tuberculous  process  in  the  lungs,  and  to  add  certain  infor- 
mation as  to  conditions  in  the  chest  which  may  be  discovered 
only  with  the  greatest  difficulty  by  the  ordinary  methods. 

In  order  to  obtain  a  correct  idea  of  the  location  and  char- 
acter of  any  intrapulmonary  condition,  it  is  practically  essen- 
tial that  stereoscopic  plates  of  the  chest  be  made,  the  ordinary 
single-plate  method  of  study  being  extremely  unsatisfactory. 


PULMONARY    TUI'.ERCULOSIS.  399 

No  greater  mistake  can  be  made  than  to  turn  a  patient,  in 
whom  one  suspects  puhnonary  tuberculosis,  over  to  the  ront- 
genologist for  a  diagnosis.  Every  physician  w^ho  is  doing 
much  chest-work  should  take  every  opportunity  to  study  per- 
sonally ;r-ray  plates  of  the  chest,  sO'  that  he  may  become 
familiar  with  the  normal  picture,  and  be  in  a  position  where 
he  can  appreciate  the  significance  of  slight  abnormalities. 
This  is  not  always  possible,  and  in  many  instances  it  may  be 
necessary  to  have  the  rontgenologist  interpret  the  plates. 
Under  these  circumstances  one  must  not  accept  too  literally 
or  too  implicitly  the  diagnosis  based  upon  the  skiagrams.  At 
its  best  the  .r-ray  reveals  only  infiltration  of  a  certain  degree 
of  density,  and  the  more  connective  tissue  or  calcareous  de- 
posits there  are  the  more  intense  the  shadow-.  One  may  find 
oneself  in  the  position  of  giving  a  bad  prognosis  in  certain 
cases  on  account  of  the  extent  of  the  lesions,  as  revealed  by 
this  method,  in  a  case  in  which  the  disease  is  practically 
arrested. 

A  good,  safe  rule,  when  one  desires  to  have  a  patient 
studied  by  the  .v-rays,  is  to  select  an  experienced,  conservative 
rontgenologist,  and  have  him  make  stereoscopic  plates  and 
study  the  case  with  the  fluoroscope.  Either  examine  the  plates 
oneself,  or  have  him  make  a  complete  report  on  the  location 
of  the  process.  Having  learned  the  evidence  desired  from  this 
method  of  study,  it  should  only  be  considered  as  one  sign  or 
symptom,  and  interpreted  only  in  its  relation  to  the  other 
available  details  of  the  clinical  picture. 

For  determining  the  presence  of  small  collections  of  fluid  in 
the  pleura,  deep-seated  abscesses,  or  collections  of  pus,  local- 
ized pneumothorax  and  similar  processes,  the  .f-ray  has  con- 
siderable practical  value,  and  in  many  obscure  conditions  the 
aid  which  it  supplies  may  be  unquestionable ;  but  it  must  be 
confessed  that  in  the  majority  of  cases  of  pulmonary  tuber- 
culosis in  which  one)  desires  assistance  from  this  method  of 
study,  it  will  prove  valueless  or  misleading. 

TREATMENT. 

The  plan  of  treatment  to  be  followed  in  the  individual  case 
of  pulmonary  tuberculosis  varies  greatly  with  the  character 
of  the  infection,    Whether  this  is  determined  by  the  virulence 


400  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

of  the  infecting  micro-organism,  the  resistance  of  the  infected 
individual,  or  a  combination  of  both,  does  not  materially  affect 
the  question.  That  the  disease  gives  rise  to  different  patho- 
logic conditions  and  clinical  features  in  different  cases  is  a 
fact  of  the  greatest  significance,  and  it  is  necessary  to  be  able 
to  distinguish  between  the  various  clinical  types  in  order  that 
one  may  select  the  appropriate  line  of  treatment  for  the  form 
of  the  disease  in  question. 

From  the  standpoint  of  treatment,  no  diagnosis  of  pul- 
monary tuberculosis  can  be  considered  complete  which  does 
not  include  the  extent  of  the  pulmonary  lesion,  its  physical 
character,  and  its  degree  of  activity  or  quiescence.  It  is  the 
failure  to  recognize  the  different  requirements  of  the  patient 
with  a  quiescent  fibroid  process  confined  to  one  apex,  for  ex- 
ample, and  those  of  the  patient  with  an  active  lesion  of  one  or 
more  lobes,  with  dense  infiltration,  and  possibly  breaking 
down  of  the  tuberculous  process,  that  is  largely  responsible 
for  the  unfavorable  results  obtained  in  the  treatment  of  the 
disease. 

The  character  of  the  disease  varies  between  the  rapidly 
extending  process  with  a  tendency  toward  caseation,  most 
commonly  seen  in  young  individuals,  and  the  fibroid  process 
of  a  slowly  advancing  nature  and  no  tendency  toward  con- 
solidation, which  ordinarily  is  accompanied  by  very  slight 
constitutional  symptoms,  usually  seen  in  older  people.  Be- 
tween these  two  types  examples  are  encountered  which  tend 
toward  one  or  the  other  extreme,  and  these  constitute  by  far 
the  greater  proportion  of  the  cases  met  wnth  clinically.  The 
terms  customarily  applied  to  these  extreme  forms  are,  phthisis 
florida  and  fibroid  phthisis,  chronic  ulcerative  tuberculosis  be- 
ing applied  to  the  intermediary  types. 

In  addition  to  these  general  forms,  there  are  exceptional 
types,  such  as  tuberculous  pneumonia  and  acute  general 
miliary  tuberculosis,  the  names  of  which  are  sufficiently 
descriptive.  In  phthisis  florida  the  disease  extends  rapidly, 
without  the  least  tendency  toward  walling-off  of  the  process, 
,and  this  results  in  the  formation  of  large  caseous  areas  and 
pneumonic  patches,  the  former  usually  showing  small  areas 
of  liquefaction  and  cavity  formation  in  the  older  portions. 
Tbe  evidence  of  systemic  toxemia  in  these  cases  may  be  ex- 


PULMONARY    TUBERCULOSIS.  401 

treme.  In  fibroid  phthisis  on  the  other  hand  the  process 
resembles  fibroid  disease  of  the  lungs,  with  the  changes  asso- 
ciated with  such  conditions,  the  symptoms  depending  upon 
the  location  and  extent  of  the  process,  and  usually  showing- 
no  toxemia,  or  but  very  sHg^ht  evidence  of  the  systemic  inroads 
of  the  poison. 

In  the  chronic  ulcerative  forms,  as  usually  encountered, 
the  disease  may  take  on  the  characters  of  one  or  the  other  of 
these  extreme  types,  depending  upon  the  extent  to  which  the 
tissues  react  to  the  tuberculous  infiltration  by  the  formation  of 
fibrous  tissue. 

Tuberculosis"  of  the  lungs  is  manifested  by  two  distinct 
processes,  one  consisting  of  the  efifect  upon  the  lung  by  the 
tubercle  bacilli  themselves,  and  the  other  resulting  from  the 
toxins  liberated  by  the  bacteria  at  the  site  of  the  lesion,  which 
ultimately  g-ain  entrance  to  the  circulation.  In  certain  in- 
dividuals the  pulmonary  disease  may  be  distinctly  progressive, 
with  very  little  evidence  of  systemic  toxemia,  and  in  others 
the  pulmonary  lesion  may  be  very  slight,  and  apparently 
fibroid,  with  marked  evidence  of  disturbance  of  the  general 
metabolism.  In  the  following  pages  the  word  "activity"  refers 
to  the  evidence  of  any  efifect  of  the  tubercle  bacilli  upon  the 
patient,  whether  localized  to  the  lung  or  general  in  character. 

For  the  proper  treatment  of  pulmonary  tuberculosis  it  is 
necessary  that,  in  addition  to  determining  the  presence  of  the 
disease,  the  examination  should  establish  the  location,  extent 
and  character  of  the  tuberculous  lesions,  and  an  accurate 
estimation  of  their  activity.  It  is  obviously  important  that 
the  patient  be  carefully  examined  for  the  presence  of  any  com- 
plications, whether  of  a  tuberculous  or  non-tuberculous  nature. 
In  determining  the  degree  of  activity,  it  is  necessary  not  only 
to  make  a  thorough  physical  examination  of  the  chest,  but 
also  to  make  a  careful  study  of  the  patient's  general  condition, 
as  shown  by  the  weight,  pulse,  and  temperature,  and  a  careful 
consideration  of  the  symptoms,  such  as  cough,  expectoration, 
gastric  disturbances,  pain,  and  general  strength  and  well- 
being.  In  the  treatment  of  the  disease,  as  an  index  of  the 
improvement  or  lack  of  improvement,  the  study  of  the  patient's 
general  condition  gives  much  more  accurate  information  than 
the  physical  examination,  in  the  majority  of  cases. 


402  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

Prevention.  It  is  only  right  and  proper  that  some  reference 
should  be  made  to  the  measures  of  preventing  the  disease  before 
describing  the  methods  of  treatment,  as  in  our  present  state 
of  knowledge  the  various  plans  devised  for  preventing  a  tuber- 
culous infection  promise  much  greater  returns  than  any 
known  method  of  treatment  of  the  disease  after  it  has  become 
implanted.  In  order  to  carry  out  intelligently  the  methods  of 
prevention,  it  is  essential  for  one  to  have  a  definite  conception 
of  the  manner  in  which  the  disease  is  transmitted,  the  mode 
of  infection,  and  the  ultimate  results  of  such  infection  in  regard 
both  to  the  invading  micro-organism  and  to  the  infected  in- 
dividual. The  entire  problem  of  infection  is  far  from  settled, 
larg'ely  because  of  the  impossibility  of  duplicating  the  natural 
conditions  in  experimental  investigations.  This  is  to  be  re- 
gretted, as  whether  infection  takes  place  by  ingestion  or  by 
inhalation,  through  the  dried  sputum  or  by  "droplet  infection," 
or  by  direct  inoculation  through  the  skin  or  mucous  mem- 
brane, is  not  merely  of  academic  interest,  but  is  a  vitally  im- 
portant question,  which  must  be  definitely  answered  before  the 
prophylaxis  of  the  disease  can  be  carried  out  in  an  efficient 
and  scientific  manner.  As  to  whether  all  primary  infections 
take  place  in  infancy  or  in  early  childhood,  does  not  appear  to 
the  writer  so  important  a  question  from  the  standpoint  of  pre- 
vention, unless  it  can  be  positivel}^  proved  that  secondary 
infection  in  adult  life  never,  or  hardly  ever,  takes  place.  In 
the  light  of  our  present  knowledge,  it  seems  absolutely  neces- 
sary to  make  every  effort  to  prevent  tuberculosis  by  checking 
the  spread  of  tubercle  bacilli  at  the  source,  namely,  the  tuber- 
culous individual  or  animal.  This  must  be  carefully  carried 
out,  either  by  insistence  upon  general  preventive  measures  or 
by  isolation  of  the  infected  individual.  The  most  essential 
necessity  in  carrying  out  such  a  method  of  prevention  is  the 
earty  detection  of  the  presence  of  the  disease,  and  the  weakest 
link  in  such  a  system  is  that  the  very  nature  of  the  disease 
makes  its  early  detection  difficult. 

The  sources  of  infection  are  tuberculous  individuals,  almost 
exclusively  those  suff'ering  from  the  pulmonary  form  of  the 
disease,  and  tuberculous  cattle,  although  the  latter  have  been 
shown  to  cause  only  a  ver}-  small  percentage  of  infections  in 
human  beings.     Granting  that  only  a   relatively   small  propor- 


PULMONARY    TUBERCULOSIS.  403 

tion  of  the  infections  are  derived  from  bovine  sources,  the 
importance  of  preventing-  the  sale  of  milk  and  meat  from 
tuberculous  cattle  must  be  in  no  way  minimized.  The  routine 
inspection  and  testing-  of  cows  used  for  supplying  milk,  and 
the  rigid  inspection  of  the  slaughtering  of  cattle,  provide  a 
protection  against  the  infection  from  these  sources  which  can- 
not be  disregarded. 

The  method  by  which  bovine  infection  may  be  prevented  is 
relatively  well-defined,  and  presents  no  great  difficulty  other 
than  that  constituted  by  the  magnitude  of  the  problem  and  the 
necessity  for  organization,  supported  by  legislation.  The  pre- 
vention of  tuberculosis  arising  from  human  sources  is  ex- 
tremely complex,  and  necessitates  measures  which  involve 
nearly  every  branch  of  human  interest  or  endeavor.  This  is 
particularly  true,  because  our  present  methods  of  preventing 
infection  at  the  source  are  lamentably  inadequate,  and  because 
of  this  fact  we  must  also  direct  our  endeavors  toward  pre- 
venting the  development  of  tuberculous  disease  in  the  infected 
individuals,  or,  if  one  does  not  accept  the  view  of  generalized 
childhood  infection,  toward  building  up  the  health  and 
strength  of  the  individuals,  so  that  they  may  be  able  to  resist 
infection  when  exposed. 

The  first  and  most  important  step  in  prevention  lies  in  the 
early  detection  of  the  sources  of  the  infecting  micro-organisms, 
and  the  second  consists  in  adopting  such  measures  as  will  pre- 
vent the  dissemination  of  the  bacilli.  This  is  the  best  that  can 
be  hoped  for  at  present,  as  isolation  of  the  tuberculous  individ- 
ual is,  in  the  first  place,  too  stupendous  an  undertaking,  and, 
secondly,  the  insistence  upon  such  a  measure  would  defeat 
itself  through  causing  the  tuberculous  to  conceal  the  fact  that 
they  were  suffering  from  the  disease.  For  the  carrying  out 
of  the  various  methods  of  prevention  it  is'  necessary  to  have  the 
support  of  public  opinion,  and  with  this  object  in  view  a  cam- 
paign of  education  is  being  everywhere  carried  out.  In  all 
educative  campaigns  great  stress  has  been  laid  upon  the  wide- 
spread nature  of  the  disease,  its  high  mortality,  and  the  infec- 
tiousness of  the  process.  The  public  has  therefore  learned  to 
view  tuberculosis  as  a  highly  contagious  disease,  which  has 
undoubtedly  caused  an  enormous  amount  of  hardships  and 
suffering  among  its  victims,  and  unfortunately   also   among 


404  DISEASES    OF    THE   EESPIRATORY    SYSTEM. 

certain  persons  who  are  merely  infected  and  not  capable  of 
transmitting-  the  disease.  It  is  to  be  regretted  that  the  respon- 
sibility for  this  failure  to  make  a  distinction  between  the  cases 
which  are  possible  sources  of  contagion  and  those  which  are 
not  rests  to  a  great  extent  upon  the  medical  profession  itself, 
but  this  fault  is  somewhat  excusable  in  view  of  the  technical 
difficulties  which  frequently  attend  the  differentiation  of  the 
two  groups  of  cases. 

Individuals  suffering  from  tuberculous  disease  of  the  lungs 
may  spread  the  tubercle  bacilli  by  carelessness  in  expectorat- 
ing the  material  coughed  up,  by  the  contamination  of  such 
articles  as  are  placed  in  the  mouth,  or  by  small,  invisible 
droplets  expelled  from  the  mouth  during  coughing,  sneez- 
ing and  laughing.  Such  people  should  be  instructed  in  the 
measures  necessary  to  prevent  the  dissemination  of  the  in- 
fective material  in  the  ways  just  indicated.  The  most  im- 
portant question  is  the  proper  disposal  of  the  expectoration, 
the  popular  idea  being  to  render  it  non-infectious  by  the  use 
of  disinfectants.  The  use  of  carbolic  acid,  bichlorid  of  mer- 
cury, and  similar  agents  in  receptacles  in  which  the  patient 
expectorates  cannot  be  too  strongly  condemned.  Their  effect 
is  merely  upon  the  surface  of  the  mucopurulent  masses,  leav- 
ing the  central  portion  still  infective,  thus  giving  a  false  sense 
of  security  which  may  be  responsible  for  harm.  The  best 
method  is  to  have  the  patient  use  paper  napkins,  or  small 
pieces  of  folded  gauze,  which  can  be  used  to  cover  the  mouth 
during  coughing,  laughing,  or  sneezing,  to  expectorate  into, 
and  to  wipe  the  mouth  with  afterward.  The  napkins  should 
be  used  but  once,  and  placed  in  paper  bags,  which  can  be 
handled  safely,  and  burned  at  frequent  intervals.  Scrupulous 
personal  cleanliness  should  be  insisted  upon  at  all  times,  fre- 
quent washing  of  the 'hands  and  lips,  and  rinsing  of  the  mouth, 
being  especially  important.  No  male  patient  should  be  per- 
mitted to  allow  hair  to  grow  on  the  face,  on  account  of  the 
opportunity  it  affords  for  collecting  small  particles  of  sputum. 
The  patient  should  have  his  own  dishes,  table  utensils,  and 
drinking  cups  or  glasses,  which  should  be  kept  separate  from 
those  used  by  the  other  members  of  the  household,  and  care- 
fully boiled  or  washed  separately  each  time  they  are  used. 
It  is  also  advisable  that  the  patient  have  his  own  sleeping- 


PULMONARY   TUBERCULOSIS.  405 

room,  and  certainly  his  own  bed.  While  the  patient  is  drowsy 
with  sleep  it  is  almost  impossible  for  him  to  care  for  the 
sputum  properly.  For  this  reason  it  is  advisable  to  have  the 
bed-linen  kept  separate,  and  boiled  before  washing-,  as  it  may 
readily  become  soiled  with  sputum.  This  is  especially  true 
when  the  cases  are  advanced  and  confined  to  bed,  in  which 
case  the  bed-linen  should  be  changed  at  frequent  intervals. 
For  the  ambulant  case  nothing  is  so  satisfactory  as  the  paper 
napkin,  which  can  be  used  and  placed  at  once  in  a  paper  bag 
carried  in  the  pocket  for  this  purpose.  Stiff  pasteboard  en- 
velopes lined  with  some  absorbent  material  also  may  be  used 
to  expectorate  into,  but  their  use  usually  excites  an  amount 
of  attention  to  the  act  which  the  patients  find  objectionable. 
The  expectorating  into  a  paper  napkin,  which  resembles  an 
ordinary  pocket-handkerchief,  is  much  less  conspicuous.  The 
use  of  sputum  cups,  of  either  the  pocket  variety  or  the  bedside 
forms  with  pasteboard  inserts,  should  not  be  encouraged,  as 
they  are  likely  to  become  soiled,  or  the  contents  spilled,  and, 
unless  care  is  exercised,  flies  easily  gain  access  to  the  sputum 
and  distribute  the  infective  material.  The  bedroom  floor 
should  have  a  wooden  or  oilcloth  covering,  tO'  permit  of  fre- 
quent cleaning  by  scrubbing  or  damp-sweeping,  never  by  dry- 
sweeping.  When  through  accident  any  article  becomes  soiled 
by  expectoration  it  should  be  cleaned  with  lye,  and  thoroughly 
scrubbed  with  soap  and  water,  or  if  the  nature  of  the  material 
of  which  it  is  compoised  does  not  permit  of  this  method  of 
cleansing  it  should  be  sterilized  by  boiling'.-  The  room  should 
be  carefully  screened,  to  exclude  flies,  and  should  be  free  of 
dampness,  and  so  arranged  as  to  permit  a  fairly-  general  exposure 
to  sunlight  and  fresh  air  (two  most  valuable  means  of  destroy- 
ing the  life  of  the  tubercle  bacillus)  ,-  there  should  be  no  dark 
corners  where  dirt  might  collect. 

This  brief  outline  of  measures  of  prevention  to  be  adopted 
for  tuberculous  patients  does  not,  however,  cover  the  entire 
subject,  as  one  must  also  use  every  means  possible  for  build- 
ing up  the  health  and  strength  of  those  in  whom  there  is  no 
tuberculous  disease. 

The  public  must,  therefore,  be  instructed,  not  only  in  the 
means  of  prevention,  but  should  be  kept  fully  informed  of  the 
dangers   of   such   predisposing-  factors    as    dissipation,    child- 


406  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

labor,  unhygienic  working  and  living  conditions,  bad  housing, 
and  insufficient  nutriment.  The  education  of  the  public  along 
these  lines  is  extremely  important,  as  it  is  only  by  means  of 
the  pressure  exerted  by  public  opinion  that  legislation  can  be 
secured  to  control  or  correct  the  existing  defective  conditions. 

It  is  impossible  to  estimate  to  what  extent  the  spread  of 
the  disease  is  diminished  by  the  earl)^  diagnosis  and  care  of 
tuberculous  disease,  especially  when  the  patients  are  segre- 
gated in  a  sanatorium  or  hospital  during  the  period  in  which 
the)'  are  potential  sources  of  infection.  In  planning  a  general 
campaign  against  the  disease,  this  is  one  of  the  points  which 
should  not  be  overlooked ;  for  while  it  is  impossible  to  gauge 
accurately,  or  even  approximately,  how  much  is  accomplished 
in  the  way  of  prevention  by  the  early  detection  of  the  infec- 
tious cases,  the  elimination  of  a  large  number  of  infective 
sources  must  be  of  enormous  value. 

General  Considerations.  When  the  diagnosis  of  pulmon- 
ary' tuberculosis  has  been  made  in  the  individual  case,  the 
question  arises  in  the  physician's  mind  as  to  which  general 
method  of  treatment  the  case  is  best  suited,  whether  the  best 
environment  would  be  at  home,  in  a  sanatorium,  or  in  a  hos- 
pital. The  answer  to  this  question  depends  upon  the  extent, 
character,  and  activity  of  the  process,  and  upon  certain 
economic  and  social  factors.  In  a  general  wa^^  it  might  be 
stated  that  sanatorium  treatment  should  be  reserved  for  pa- 
tients with  slight  active  pulmonary  involvement  uncompli- 
cated by  tuberculosis  in  any  other  part  of  the  body,  and  hos- 
pital treatment  for  those  with  extensive  pulmonary  tuber- 
culosis, or  slight  involvement  of  the  lungs,  complicated  by 
tuberculosis  in  some  other  part  of  the  body,  or  by  some  other 
disease. 

There  are  several  exceptions  to  this  very  general  rule,  to 
be  considered  later,  but  both  methods  of  treatment  should  be 
considered  at  best  but  temporary  measures  during  the  period 
of  activity.  The  question  of  cure  in  the  majority  of  cases  is 
ultimateh^  determined  b}^  the  home  surroundings,  and  by  the 
conditions  under  which  the  patient  works.  The  ability  to 
stay  in  a  sanatorium  or  hospital  for  a  period  of  time  suffi- 
cient to  bring  about  a  complete  arrest  or  cure  is  only  possessed 
by  the  exceptional  patient.     It  is  the  failure  to  recognize  this 


PULMONARY    TUBERCULOSIS.  407 

fact    which    has    given    rise    to    tlie    feeling-   that    our   present 
methods  of  treatment  are  entirely  inadequate. 

Sanatorium  treatment  possesses  many  advantages  over 
home  treatment,  the  most  important  being-  the  following: 

The  patient  finds  it  much  easier  to  follow  a  method  of 
living-  similar  to  that  of.  those  by  whom  he  is  surrounded. 
The  living-  out  of  doors  is  much  easier  and  more  congenial, 
and  the  air  is  much  less  likely  to  be  contaminated.  A  gen- 
erous and  well-regulated  diet  is  more  easily  obtained  than  in 
the  average  home.  The  regulation  of  the  amount  and  char- 
acter of  the  rest  and  exercise  is  more  easily  controlled. 

The  mental  stimulation  derived  from  association  with, 
patients  who  have  improved  is  of  inestimable  value.  The 
patient  receives  an  education  in  the  methods  of  prevention 
and  treatment,  and  obtains  a  general  knowledge  of  the  disease 
and  its  various  manifestations  and  complications  which  it  is 
almost  impossible  to  secure  in  any  other  way. 

The  method  has  certain  disadvantages,  which  must  be 
taken  into  consideration,  although  they  are  more  than  coun- 
terbalanced by  the  advantages.  The  most  serious  disadvan- 
tages of  a  sanatorium  regime  are  as  follows : 

The  separation  of  the  patient  from  his  family,  which, 
while  usually  a  distinct  advantage,  may  at  times  be  a  serious 
disadvantage,  especially  when  he  is  so  far  removed  as  to  make 
the  visits  of  members  of  his  family  prohibitory.  This  is  espe- 
cially true  of  the  more  advanced  cases.  Occasionally  the 
patient  becomes  mentally  depressed  from,  the  association  with 
so  many  sick  people,  this  being  mainly  on  account  of  the 
vicious  habit,  so  common  to  sanatoria,  and  so  difficult  to  sup- 
press, of  the  patients  discussing  their  symptoms  among 
themselves. 

The  lack  of  individual  attention  is  sometimes  experienced 
by  patients  in  sanatoria  where  large  numbers  of  cases  are 
treated,  and  where  necessarily  a  certain  amount  of  routine 
must  be  maintained. 

The  worst  defect  of  the  sanatorium  lies  in  the  fact  that  so 
much  is  done  for  the  individual  that  there  is  a  risk  that  he  may 
lose  that  self-reliance  so  essential  for  his  future  welfare. 

There  are  other  factors  which  may  influence  the  selection 
of  sanatorium  treatment,  such  as  bad  housing  or  living  con- 


408  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

ditions,  lack  of  necessary  care  and  attention  at  home,  vicious 
associations  or  habits,  etc. 

Sanatorium  and  hospital  treatment  have  the  advantage  of 
removing  from  the  family  a  possible  source  of  contagion  dur- 
ing the  period  of  infectivity.  This  is  a  point  to  be  constantly 
borne  in  mind  in  regard  to  patients  in  whom  for  any  reason 
there  is  cause  to  doubt  their  complete  co-operation  in  the 
carrying  out  of  the  necessary  preventive  measures. 

Hospital  treatment  may  also  be  found  temporarily  neces- 
sary in  patients  in  whom  the  disease  has  pursued  an  inactive 
course,  during  periods  of  acute  exacerbation. 

The  home  treatment  of  the  disease  is,  after  all,  the  most 
important  for  the  average  physician  thoroughly  to  under- 
stand and  appreciate,  and  for  this  reason  the  various  meas- 
ures of  treatment  will  be  given  as  they  can  be  applied  in  the 
patient's  home,  where,  with  considerable  patience  and  atten- 
tion to  detail,  many  of  the  advantages  of  the  sanatorium  can 
be  secured. 

There  is  probably  no  other  disease  in  the  treatment  of 
which  it  is  so  necessary  to  exercise  patience,  perseverance,  en- 
couragement, and  constant  attention  to  every  apparently 
trivial  detail.  It  is  frequently  the  little  detail  of  treatment 
repeated  over  long  periods  of  time  which  may  finally  deter- 
mine the  question  of  success  or  failure  in  the  attempt  to  over- 
come this  insidious  and  stubborn  disease. 

Climate.  The  value  of  certain  climates  in  the  treatment  of 
tuberculosis  is  so  firmly  implanted  in  the  minds  of  many 
medical  men,  as  well  as  members  of  the  laity,  and  the  virtues 
of  these  climates  are  so  frequently  extolled  by  intelligent  and 
reliable  members  of  the  profession,  that  it  is  with  considerable 
hesitancy  that  one  gives  expression  to  views  upon  this  sub- 
ject which  may  not  be  in  accord  with  those  commonly  held. 
When  one  comes  to  a  careful  consideration  of  the  question  of 
climate,  one  finds  that  there  is  a  curious  lack  of  uniformity  in 
the  various  climates  recommended  in  the  treatment  of  tuber- 
culosis, and  that  they  do  not  seem  to  possess  any  physical 
property  in  common.  One  is  forced  to  conclude  that  the 
claims  of  these  various  climates  must  rest  largely  upon  the 
fact  that  the  medical  men  in  the  various  resorts,  through  their 
wide  experience,  and  possibly  by  virtue  of  their  personal  in- 


PULMONARY    TUBERCULOSIS.  409 

terest  in  the  disease,  have  l)een  better  a1)le  to  treat  the  pa- 
tients, and  probably  have  had  them  under  better  control  than 
could  be  secured  in  their  own  homes.  Equally  good  results 
seem  to  be  obtained  in  sanatoria  situated  in  regions  for  which 
no  great  claims  are  made,  so  far  as  climate  is  concerned,  and 
where  the  only  climatic  factors  they  possess  to  recommend 
them  is  air  uncontaminated  by  the  dust  and  smoke  of  a  large 
city.  It  must  be  recognized  that  the  patients  who  have  been 
under  treatment  for  some  time  not  infrequently  show  a  tem- 
porary improvement  under  the  stimulation  of  change  in  scene 
and  surroundings.  There  are  also  certain  parts  of  the  country 
where,  on  account  of  climatic  conditions,  it  is  much  easier  for 
the  patient  in  search  of  out-door  life  to  pursue  the  mode  of 
life  so  desirable,  if  not  essential,  for  their  recovery. 

In  deciding  where  to  send  a  patient  suffering  from  pul- 
monary tuberculosis,  the  most  important  considerations 
should  be  the  skill  and  experience  of  the  medical  attendants, 
and  the  equipment  for  carrying  out  the  necessary  treatment, 
rather  than  any  reputed  climatic  advantages  of  the  location. 

Fresh  Air.  It  is  not  necessary  to  analyze  or  to  attempt  to, 
determine  the  essential  feature  of  fresh  air,  which  makes  it  so 
valuable  in  the  treatment  of  pulmonary  tuberculosis.  The 
fact  remains  that  there  is  probably  no  one  factor  which  is  so 
important  in  the  treatment  of  this  disease  as  an  unlimited  sup- 
ply of  fresh  air.  It  is  very  fortunate  that  so  important  an  aid 
to  treatment  is  so  very  easy  to  secure  in  practically  an  un- 
limited supply,  although  the  very  ease  with  which  it  is  ob- 
tained probably  is  largely  responsible  for  the  extent  to  which 
it  has  been  neglected  in  the  past. 

There  are  several  points  which  must  be  emphasized  in 
regard  to  fresh  air,  which  may  appear  extremely  trivial  and 
yet  are  so  important  that  they  will  bear  repeating.  The  main 
point  to  be  recalled  is  that  the  desired  object  is  to  obtain  a  supply 
of  air  to  the  respiratory  tract  in  the  greatest  possible  degree 
of  purity  and  freshness,  and  at  tlie  same  time  to  keep  the  patient 
comfortable.  The  first  object  is  easily  obtained  by  keeping  the 
patient  outdoors  as  much  as  possible,  and  seeing  to  it  that 
when  not  outdoors  there  is  a  sufficient  supply  of  fresh  air 
indoors.  .  In  the  localities  where  the  houses  are  not  too  close 
together,  sleeping  porches  may  be  utilized,  or  in  lieu  of  this 


410  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

an  ordinary  porch  may  be  used,  or  even  a  yard  or  roof  may 
serve  the  purpose.  A  room  well  supplied  with  windows,  kept 
open  as  far  as  possible  from  the  top  and  bottom,  or  with  the 
sashes  removed,  answers  almost  as  well  as  the  sleeping-  porch. 
Some  patients  object  to  the  draught  caused  by  open  windows, 
under  which  circumstances  considerable  comfort  may  be  de- 
rived from  the  use  of  a  small  screen  which  will  prevent  the 
air  from  blowing  directly  upon  the  patient,  the  comfort  of 
whom  must  be  respected,  if  one  expects  him  to  persevere  in 
living  in  the  fresh  air.  One  must,  therefore,  see  that  the  bed- 
clothes are  sufficiently  heav}^  and  that  the  bed  is  made 
properly.  In  very  cold  weather  it  is  advisable  to  see  that  there 
is  adequate  protection  beneath  the  mattress  as  well  as  over  it, 
and,  where  the  bed  is  exposed,  a  light  rubber  covering  should 
be  provided  for  stormy  weather.  The  so-called  "Klondike 
bed"  is  a  very  convenient  and  comfortable  method  of  making 
the  bed  during  the  extreme  weather,  as  it  not  only  provides 
blankets  beneath  as  well  as  over  the  patient,  but  the  blankets 
are  arranged  so  as  to  prevent  anj^  air  leaking  in  around  the 
edges.  Sleeping-bags  made  of  special  blanket  material  are 
preferred  bv  many  patients,  as  they  are  less  likely  to  become 
disarranged  by  moving  about  in  the  bed.  The  object  to  be 
obtained  by  such  sleeping  accommodations  is  the  exclusion 
of  the  cold  air,  and  to  keep  the  bedclothes  as  close  to  the 
patient  as  possible,  so  that  it  will  not  be  possible  to  dissipate 
much  heat  bv  warming  a  large  air-space  beneath  the  covers. 
In  cold  and  damp  weather  the  bed  should  be  dried  and 
warmed  before  the  patient  gets  into  it,  otherwise  there  may  be 
suffering  from  the  chilling.  The  patient  must  wear  sufficient 
underclothing  at  night,  and  a  woolen  nightcap  or  similar  cov- 
ering for  the  head  is  almost  essential  when  sleeping  out  of 
doors.  AMien  sleeping  outdoors  such  patients  as  require  abso- 
lute darkness  in  order  to  sleep  may  resort  to  an  opaque 
bandage  applied  over  the  eyes.  AA^here  the  sleeping-quarters 
are  limited,  and  the  necessity  arises  of  keeping  the  remainder 
of  the  room  warm,  a  window  tent  will  be  found  to  be  a  great 
convenience,  as  the  head  of  the  bed  may  be  placed  outside  the 
window,  or  immediately  beside  it,  and  the  fresh  air  supplied 
directly  to  the  patient's  face  and  excluded  from  the  remainder 
of  the  room.    These  window  tents  may  be  purchased,  or  made 


PULMONARY    TUBERCULOSIS. 


411 


Pig.  15. 


Pig.  16. 


Figs.    IS    and    16. — Showing   home-made    window-tent,    open    and 
closed.     (Henry  Phipps  Institute,  University  of  Pennsylvania.) 


412  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

at  home,  as  the  patient's  circumstances  dictate.  An  inexpen- 
sive home-made  window  tent,  which  can  be  easily  made  out 
of  hea\y  canvas  duck,  with  a  simple  wooden  frame,  is  illus- 
trated on  page  411,  An  awning  on  the  outside  of  the  windows 
offers  protection  from  wind,  sun,  rain,  or  snow,  and  insures 
privacy. 

For  resting  outdoors,  ''taking  the  cure,"  as  it  is  called,  an 
easy  reclining  chair  is  necessary,  a  steamer  chair  or  Adiron- 
dack recHning  chair  ansvrering  the  purpose  very  well,  with 
the  patient  well  protected  against  the  cold  by  means  of 
steamer  blankets  or  sitting-out  bag.  The  patient's  feet  must 
be  warmlv  and  loosely  covered  when  sitting  out,  the  ordinary 
tight  leather  shoe  not  being  suited  to  this  purpose.  A  warm 
room  in  which  to  dress  and  undress,  bathe,  and  eat  is  an  addi- 
tional indispensable  comfort  to  the  patient  living  outdoors. 

Tlie  patient  with  pulmonar^^  tuberculosis  should  be  kept  in 
the  open  air  or  fresh  air  the  entire  twenty-four  hours,  except 
for  the  time  necessary  in  which  to  dress,  undress,  eat,  and 
bathe,  with  an  occasional  half-hour  for  writing,  sewing,  or 
duties  of  like  nature  which  cannot  be  performed  in  the  open 
air  in  very  cold  weather. 

]\Iost  of  the  suggestions  for  the  comfort  of  the  patient 
refer  to  verj-  cold  weather,  and  yet  it  is  just  as  important  to 
look  after  the  patient  during  the  warm  days.  The  patient 
must  be  protected  from  the  direct  rays  of  the  sun  at  all  times 
when  sitting  out,  except  when  otherwise  ordered  by  the 
physician,  must  not  be  wrapped  up  too  much  for  comfort,  and 
is  to  be  protected  from  mosquitoes,  flies,  and  other  warm 
weather  pests. 

Rest  and  Exercise.  In  the  management  of  a  case  of  tuber- 
culosis, rest  and  exercise  are  two  extremely  valuable  aids, 
when  properly  regulated  in  the  individual  case.  While  rest 
may  be  rarely  applied  improperly,  so  that  a  patient  may  pos- 
sibly derive  harm  from  its  abuse,  it  is  exercise  which  is  usu- 
ally misapplied,  and  to  mistakes  on  this  score  are  referable 
great  possibilities  for  injur\^  to  the  patient.  The  importance 
of  rest  in  any  patient  with  active  pulmonary  tuberculosis  is 
beyond  question,  and  by  "rest"  is  meant  absolute  rest  in  bed 
during  the  entire  twenty-four  hours.  It  is  even  advisable  to 
put  to  bed  every  patient  with  pulmonary  tuberculosis  when 


PULMONARY    TUBERCULOSIS.  413 

lirst  coming  under  treatment,  until  they  have  been  kept  under 
observation  for  a  sufficient  length  of  time  to  determine  their 
temperature  and  pulse  when  at  absolute  rest.  One  is  then  in 
a  very  much  better  position  to  direct  the  future  treatment  of 
that  individual  patient,  and  it  also  provides  an  index  with 
which  to  compare  the  effect  of  treatment. 

When  to  discontinue  the  absolute  rest  in  bed,  and  to  allow 
the  patient  to  g'et  up,  dress,  and  sit  outdoors,  is  a  question 
which  must  be  determined  in  each  individual  case.  In  the 
face  of  a  subsidence  of  the  original  physical  signs.,  a  gain  in 
weight,  a  pulse-rate  approximating  100  in  the  afternoon,  with 
fever  not  above  991/5°  or  99%°  F.  (37.5°  or  37.7°  C),  and  an 
absence  of  all  complications,  the  patient  may  be  allowed  to  sit 
outdoors,  or  to  "take  the  cure,"  as  it  is  called  (Fig.  17,  B). 

The  necessity  of  an  accurate  daily  record  of  pulse  and  tem- 
perature in  the  early  part  of  the  treatment  cannot  be  too 
strongly  usged,  since  these  data  supply  information  absolutely 
necessary  for  the  intelligent  treatment  of  these  cases.  A  few 
precautions  may  not  be  amiss  in  reference  to  the  taking  of  the 
pulse  and  temperature.  The  pulse  should  be  taken  after  the 
patient  has  been  resting  for  at  least  one-half  hour,  and  this 
also  applies  to  the  taking  of  temperature.  The  temperature 
should  never  be  taken  directly  after  the  patient  has  been 
drinking  anything  hot  or  cold.  The  thermometer  should  be 
placed  well  under  the  tongue  and  retained  in  the  mouth,  with 
the  lips  tightly  closed,  for  ten  full  minutes.  It  does  not  make 
any  difference  whether  the  thermometer  is  a  "half-minute"  or 
a  "two-minute"  thermometer,  it  must  be  kept  in  the  mouth 
ten  minutes,  as  with  so  much  depending  upon  such  a  slight 
variation  as  one  degree  above  normal,  or  less,  no  thermometer 
can  be  depended  upon  to  register  accurately  in  less  than  ten 
full  minutes. 

The  stage  at  which  the  tuberculous  patient  may  be  per- 
mitted to  exercise,  is  an  extremely  important  question  to  de- 
cide, and  one  for  which  it  is  difficult  to  lay  down  fixed  gen- 
eral rules.  It  is  really  a  question  to  be  decided  in  the  individ- 
ual case,  the  decision  being  formed  by  the  extent  and  char- 
acter of  the  pulmonary  lesion,  the  presence  or  absence  of  com- 
plications, the  duration  of  the  cure,  the  weight  and  general 
condition  of  the  patient. 


414  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

In  a  broad .  way,  one  might  state  that  no  patient  should  be 
allowed  exercise  so  long  as  there  is  evidence  of  active  lesions 
in  the  lung.  AMiere  no  contraindications  exist,  the  pulse-rate 
and  the  temperature  are  the  best  guides  in  permitting  exer- 
cise, and  controlling  it  after  it  has  been  allowed.  A  good  con- 
servative rule,  to  which  there  are  certain  exceptions,  is  not 
to  allows  any  patient  to  take  exercise  until  the  afternoon  tem- 
perature (or  maximum  daily  temperature)  is  below  99°  F. 
{Z7.?)°  C),  and  the  pulse-rate  90  or  less  when  at  rest  (Fig  17, 
D).  The  exercise  should  be  discontinued  if  the  temperature 
or  pulse  show  any  tendency  to  rise,  w^hen  taken  at  the  end  of 
one-half  hour's  rest  after  the  exercise.  The  exercise  should 
also  be  discontinued  upon  the  appearance  of  any  unfavorable 
symptom  or  sign,  such  as  loss  of  weight,  dyspnea,  hemoptysis, 
pleurisy,  fatigue,  etc.  There  is  a  fairly-  large  group  of  patients 
who  do  not  present  a  high  afternoon  temperature,  and  in  fact 
the  afternoon  temperature  ma^^  be  normal,  but  in  w^hom  the 
morning  temperature  is  markedl}^  subnormal  (Fig.  17,  C). 
One  must  be  extremely  cautious  in  permitting  exercise  in  these 
cases  with  a  wide  daily  variation  in  temperature  until  the 
morning  temperature  more  nearly  approaches  normal  (Fig.  17, 
D).  These  cases  usually  have  a  high  pulse-rate,  which  will 
serve  as  a  warning,  but  is  not  always  true,  for  the  pulse  at 
times  is  relatively  slow^ 

Having  determined  the  advisability  of  exercise,  the  ques- 
tion arises  as  to  the  form  in  w^hich  it  is  to  be  given  and  how 
far  it  is  to  be  pushed.  Undoubtedly  the  best  form  of  exercise 
in  the  early  part  of  the  treatment  is  walking,  and  at  first  this 
should  be  allowed  only  for  five  or  ten  minutes  a  day,  until  it 
has  been  demonstrated  that  the  exercise  is  not  followed  by 
any  deleterious  effect,  as  evidenced  by  the  temperature  and 
pulse.  It  has  also  been  suggested  that  the  blood-pressure  may 
serve  as  a  guide  to  the  advisability  of  continuing  the  exercise, 
a  slight  drop  in  the  blood-pressure  following  a  rest-period 
after  the  exercise,  or  a  decided  drop  in  pressure  immediately 
after  the  exercise,  being  an  indication  that  the  activit}^  should 
be  diminished.  Even  a  slight  drop  is  to  be  considered  a  suffi- 
cient contraindication  to  an  increase  of  the  amount  of  exercise. 
"While  it  has  been  suggested  that  the  blood-pressure  ser\'es  as 
an  excellent  guide,  the  temperature   and  pulse-rate,  if  accu- 


PULMONARY   TUBERCULOSIS. 


415 


rately  recorded,  should  provide  one  with  sufficient  information 
to  gauge  accurately  the  amount  of  exercise  to  be  permitted.  If 
the  temperature  and  pulse,  taken  one-half  hour  after  the  walk, 
show  no  distinct  increase,  the  walk  may  be  lengthened  from 
two  to  five  minutes  daily,  until  the  patient  is  taking  from  one 
to  three  hours'  walk.  It  may  usually  be  found  beneficial  to 
supplement  the  walk  with  work  of  some  form,  whenever  the 
walk  has  reached  two  hours,  in  order  to  provide  some  inter- 
est to  the  exercise,  for  walking  soon  may  become  very  monot- 
onous. The  main  objection  to  games  in  the  open  air,  for  arrested 
cases,  consists  in  the  fact  that  the  interest  excited  by  the  game. 


Fig.  17. — Showing  various  types  of  temperature  records  met 
with  in  different  stages  of  tuberculous  disease  of  the  lungs  (see 
text) . 


especially  if  there  is  any  competition  involved,  leads  the 
individual  to  overexert  himself;  or  to  become  overfatigued. 
The  problem  of  providing  amusement  for  the  patient  on  rest 
is  a  very  serious  one,  as  it  is  difficult  for  the  patient  to  keep 
his  mind  occupied  with  such  games  as  chess,  checkers,  par- 
chesi,  and  cards.  Sewing  or  crocheting  may  be  permitted  in 
moderation,  and  reading,  if  some  supervision  is  maintained, 
so  that  reading  books  of  too  depressing-  or  of  too  serious  a 
nature  is  avoided.  Studying  should  be  absolutely  prohibited 
until  the  patient  is  on  a  considerable  amount  of  exercise.  The 
only  points  to  be  borne  in  mind  in  selecting  the  work  are, 
that  the  work  should  be  as  much  as  possible  in  the  open  air, 
should  always  be  stopped  short  of  fatigue,  and  should  not 


416  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

require  any  violent  straining  eftort.  There  is  no  reason  why 
an  early  case  of  pulmonary  tuberculosis  should  not  gradually 
work  up  to  eight  hours  exercise  a  day,  and  it  is  beyond  ques- 
tion that  exercise,  when  properly  controlled,  has  an  extremely 
beneficial  effect  upon  the  patient's  general  condition.  There  is  one 
point  of  extreme  importance,  and  one  which  does  not  receive  the 
attention  it  should,  namely,  the  very  injurious  results  which 
may  follow  deep-breathing  exercises.  So  long  as  there  is  any 
activity,  or  any  reason  to  suspect  activity  of  the  tuberculous 
process,  all  deep-breathing  exercises  should  be  absolutely  for- 
bidden. Deep-breathing  as  a  health  measure,  has  been  so  fre- 
quently recommended  to  the  laity,  especially  Avhere  there  is 
any  reason  to  suspect  pulmonar}^  disease,  that  patients  will 
frequently  adopt  this  procedure  without  the  advice  of  their 
physician.  This  fact  should  be  constantly  remembered,  and 
patients  warned  of  the  dangers  resulting  from  this  apparently 
harmless  form  of  exercise.  A\'hile  not  going  so  far  as  to  say 
that  deep-breathing  is  harmful  or  useless  in  health}-  individ- 
uals, or  in  people  with  no  active  pulmonary  disease,  one  must 
admit  that  the  value  of  the  measure  is  certainly  very  much 
overrated.  Anyone  who  has  had  under  observation  many 
cases  of  tuberculosis  w^ith  extensive  pulmonar^^  invasion  must 
have  been  impressed  with  the  relatively  small  amount  of  func- 
tioning- lung  tissue  necessarv  to  meet  the  ordinan^  demands  of 
life.  The  dyspnea  occasionally  encountered  in  this  disease 
does  not  appear  to  be  dependent  upon  the  amount  of  lung  tis- 
sue affected,  but  upon  some  other  factor,  many  of  the  worst 
cases  met  with  being  patients  with  only  a  relatively  small 
crippling  of  the  aerating  surface  of  the  lungs. 

Diet.  Fresh  air,  rest,  and  exercise  do  not,  as  a  rule,  otter 
any  very  serious  problem  in  the  average  cases,  although  they 
require  careful  control,  and  the  exercise  of  judgment  in  their 
application.  To  secure  a  well-balanced,  varied,  nutritious, 
digestible  diet  in  sufficient  quantity,  will  frequently  tax  the 
patience,  perseverance,  ingenuity,  and  resourcefulness  of  the 
physician  in  attendance.  In  institutions  for  the  treatment  of 
tuberculosis  it  is  advisable  to  study  carefully  the  amount  of 
food  per  patient  consumed  daily,  and  accurately  to  measure 
the  food  used,  so  as  to  determine  the  number  of  calories  each 
patient  is  receiving  daily,  and  the  proportion  of  protein,  fat, 


PULMONARY   TUBERCULOSIS.  417 

and  carbohydrate.  This  is  necessary,  not  only  that  we  may 
learn  what  is  the  diet  which  seems  to  give  the  best  results 
in  the  majority  of  cases,  but  also  to  ascertain  how  that  diet 
may  be  provided  most  economically.  In  practice,  however,  it 
seems  best,  in  view  of  our  present  lack  of  knowledge,  not  to 
attempt  the  weighing  of  the  patient's  food,  but  to  provide  that 
diet  which  seems  best  suited  to  the  needs  of  the  individual. 
If  one  should  be  interested  in  determining,  for  comparison, 
the  caloric  value  of  the  food  consumed,  and  in  estimating  the 
proportion  of  protein,  fat,  and  carbohydrates  consumed  daily, 
it  may  be  stated  that  according  to  the  most  reliable  studies  we 
possess  the  total  value  for  one  day  should  be  about  3200 
calories,  with  about  100  to  130  grams  (3  oz.  230  gr.  to  4  oz. 
255  gr.)  of  protein,  100  to  110  grams  (3  oz.  230  gr.  to  3  oz. 
384  gr.)  of  fat,  and  carbohydrates  sufficient  to  bring  the  diet 
up  to  the  required  value.  It  would  be  impossible  to  attempt 
to  describe  in  detail  the  various  articles  of  diet  which  might 
be  resorted  to  in  various  conditions.  The  foods  which  have 
proved  of  most  value  in  the  majority  of  cases  form  the  so-called 
milk-and-egg  diet.  This  possesses  so  many  advantages  that  it 
should  be  given  a  fair  trial  in  every  case,  and  not  discarded 
until  it  has  been  clearly  proved  unsuited  to  the  individual  pa- 
tient. In  the  first  place  it  is  usually  readily  obtained,  and,  as 
a  rule,  is  not  extremely  expensive ;  furthermore,  milk  and  eggs 
can  be  accurately  and  easily  measured  by  the  patient,  which 
allows  of  a  ready  increase  or  decrease  in  the  quantity,  and  the 
patient  can  usually  take  them  even  when  there  is  not  very 
much  appetite.  Milk  has  the  advantage  of  being  a  well-bal- 
anced food  which  does  not  tax  the  digestive  powers  of  the 
invalids,  and  while  the  bulk  is  a  distinct  disadvantage,  it  is 
usually  not  a  serious  one.  It  is  especially  valuable  for  the 
reason  that  it  may  be  given  at  relatively  frequent  intervals.  A 
very  common  mistake  in  giving  this  diet,  and  one  that  has 
been  largely  responsible  for  many  of  the  failures  to  obtain 
good  results  from  its  use,  is  the  failure  to  limit  the  amount 
of  solid  food  consumed  while  the  patient  is  taking  large  quan- 
tities of  milk  and  eggs. 

It  is  extremely  important  that  the  patient  be  instructed 
carefully  about  the  amount  of  milk  and  eggs  to  be  taken,  and 
also  be  told  just  when  to  take  them.     It  will  be  found  most 


418  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

satisfactory  to  write  out  for  the  patient  a  daily  diet  schedule, 
with  the  quantity  and  time  for  taking  accurately  recorded. 
In  this  way  mistakes  can  be  avoided  which  it  is  possible  may 
prove  serious  in  some  cases.  It  is  difficult  to  outline  in  detail 
a  diet  satisfactory  for  every  case,  but  the  effort  will  be  made 
to  give  a  daily  diet  schedule  which  will  at  least  serve  as  a 
basis  for  treatment,  with  such  modifications  as  may  be  needed 
in  the  individual  case.  It  is  customary  in  referring  to  the  diet 
to  speak  of  a  "twelve-six"  or  an  "eight-four"  diet,  or  some 
such  combination  of  figures,  the  first  figure  referring  to  the 
number  of  glasses  of  milk  taken  daily  (reckoning  four  glasses 
to  a  quart),  and  the  second  to  the  number  of  eggs.  In  the 
average  patient  it  will  be  found  best  to  start  in  with  eight 
glasses  of  milk,  four  eggs,  and  but  one  meal  daily.  If  it  is 
found  that  the  patient  gains  weight  upon  this  quantity  of 
food,  and  hunger  seems  to  be  satisfied,  it  may  be  maintained, 
or  the  milk  and  eggs  can  readily  be  increased  if  there  is  a  fail- 
ure to  gain  in  weight.  The  disadvantage  of  starting  the  pa- 
tient with  a  "twelve-six"  diet  is  that  it  may  be  found  too  much 
for  proper  assimilation,  and  may  create  a  distaste  for  the  diet 
which  it  may  be  impossible  to  overcome.  A  sample  dietary 
of  a  patient  on  an  "eight-four"  diet  would  be  as  follows : 

Two  glasses  of  milk  and  two  eggs. 

Two  glasses  of  milk. 

Dinner — Meat    and  vegetables;    fruit    for    dessert 

by  preference. 
Two  glasses  of  milk. 
Two  glasses  of  milk  and  two  eggs. 

When  the  patients  are  not  exercising  they  frequently  do 
better  if  a  longer  interval  is  allowed  to  elapse  after  the  mid- 
day meal,  the  two  afternoon  feedings  being  given  at  5  and  7.30, 
or  at  6  and  8.30  p.m.  The  milk  may  be  given  cold  or  at  room 
temperature,  as  the  patient  prefers,  even  being  slightly 
warmed  if  desired.  The  milk  should  be  swallowed  slowly,  and 
not  gulped  down  in  large  quantities,  or  merely  sipped.  In 
very  cold  weather  it  will  usually  be  found  that  the  patient 
will  appreciate  very  much  a  warm  drink  in  the  morning,  such 
as  weak  coffee  or  one  of  its  substitutes,  or  hot  cocoa. 

The  method  of  taking  the  eggs  may  usually  be  left  to  the 
preference  of  the  patient,  who  usually  finds  it  most  satisfac- 


7.30 

A.M. 

.0.00 

A.M. 

1.00 

P.M. 

4.00 

P.M. 

6.30 

P.M. 

PULMONARY   TUBERCULOSIS.  419 

tory  to  swallow  the  eggs  whole,  or  to  swallow  the  yolk  and 
white  separately,  without  breaking  the  former.  This  method 
has  the  advantage  that  the  egg  is  practically  tasteless,  which 
will  be  found  to  be  a  great  advantage. 

Tlie  swallowing  of  the  eggs  may  be  facilitated  by  placing 
them  in  a  glass  and  covering  with  a  small  quantity  of  milk, 
orange-juice,  or  something  of  the  kind.  If  the  patient  prefers 
to  take  the  egg  in  the  milk,  they  should  be  well  mixed  by 
shaking  together,  and  then  strained  before  drinking.  If  pos- 
sible they  should  be  taken  with  very  little,  if  any,  flavoring, 
preferably  not  sweetened,  and  the  common  practice  of  adding 
sherry,  whiskey,  or  brandy  to  the  milk-and-egg  mixture, 
should  only  be  resorted  to  in  exceptional  cases. 

Some  patients  have  a  firm  belief  that  they  are  unable  to 
take  milk,  believing  that  it  does  not  agree  with  them.  An 
effort  should  be  made  to  alter  this  view  if  possible,  assuring 
them  that  not  infrequently  people  suffer  from  gastric 
and  intestinal  disturbances  for  the  first  week  or  two  before 
the  gastro-intestinal  tract  becomes  accustomed  to  taking  care 
of  that  form  of  food.  If  the  prejudice  is  very  strong,  milk  may 
be  given  in  very  small  quantities,  a  few  ounces,  once  or  twice 
a  day  and  gradually  increased  in  quantity,  as  the  patient  finds 
he  suffers  no  ill  effect.  The  whole-milk  should  be  used  by 
preference,  but  occasionally  it  may  be  found  necessary  to 
resort  to  buttermilk  (prepared  from  the  whole-milk),  koumiss, 
or  some  similar  beverage,  and,  as  a  final  resort,  the  malted 
milk  preparations  may  be  tried  for  a  short  period,  as  a  sub- 
stitute for  the  raw  milk. 

Occasionally  patients  will  be  encountered  who  are  unable 
to  take  the  eggs,  even  after  repeated  attempts.  Sometimes 
they  can  take  the  eggs  if  cooked,  but  even  then  it  will  be  found 
impossible  to  give  them  in  the  same  quantity  as  when  taken 
raw,  and  the  patients  soon  tire  of  them.  When  the  patients 
are  unable  to  take  the  eggs,  or  it  is  found  impossible  to  secure 
eggs  that  are  absolutely  fresh,  certain  changes  have  to  be 
made  in  the  dietary  to  provide  sufificient  nutriment.  Solid  food 
will  have  to  be  provided  at  the  morning  and  evening-  meals, 
to  take  the  place  of  the  eggs,  allowing-  a  longer  interval  to 
elapse  before  taking  food  again  than  would  be  necessary  after 
taking  eggs.     At  times  patients  find  it  impossible  to  take  the 


420  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

inilk-and-egg-  diet  after  persistent  efforts,  in  which  case  it  is 
advisable  to  resort  to  three  meals  a  day,  care  being  taken  to 
see  that  an  interval  of  four  to  five  hours,  between  meals  is 
provided.  If  it  is  found  that  the  patient  fails  to  gain  on  the 
ordinary  food,  the  three  meals  may  be  supplemented  by  the 
addition  of  olive  oil  or  cod-liver  oil,  and  the  patient  advised 
as  to  the  quantity  and  character  of  food  to  be  taken,  so  that 
the  meals  may  provide  the  greatest  nutritive  material  for  the 
amount  of  food  taken.  This  is  extremely  important,  as  the 
average  layman  is  woefully  ignorant  about  the  nutritive  or 
caloric  value  of  foodstuffs. 

It  might  not  be  amiss  to  mention  some  of  the  precautions 
to  be  observed  when  three  meals  are  taken,  arid  although  some 
of  these  may  appear  trivial  and  commonplace,  their  impor- 
tance is  such  that  they  are  worth  repeating.  Fried  foods 
should  be  avoided,  all  foods  being  prepared  by  roasting,  broil- 
ing, boiling,  or  baking.  Hot  cakes  and  hot  breads  of  various  kinds 
should  never  be  taken,  bread  somewhat  stale,  or  toasted,  being 
by  far  the  best  way  in  which  to  take  this  form  of  food.  Pas- 
tries also  are  very  objectionable,  the  desserts  to  be  preferred 
being  custards,  rice,  sago,  cornstarch,  and  similar  prepara- 
tions. Fruit  also  is  a  desirable  article  of  diet  at  the  completion 
of  a  meal.  Some  of  the  articles  of  diet  which  may  be  found  to 
be  of  benefit  are  rolled  oats,  wheat  preparations,  cocoa,  peas, 
beans,  potatoes,  rice,  butter,  macaroni,  cornmeal  mush,  lamb, 
beef,  chicken,  fish,  bacon,  nuts,  raisins',  and  dates.  Soups 
should  preferably  be  in  the  form  of  a  puree. 

While  this  list  is  extremely  brief  and  does  not  in  any  way 
begin  to  designate  every  food  which  ma}-  be  taken,  the  articles 
mentioned  are  the  ones  upon  which  special  emphasis  should 
be  laid.  The  majority  of  patients  must  be  instructed  to  eat 
slowly  and  to  chew  the  food  thorough^  before  swallowing  it. 
It  is  important  to  see  that  the  teeth  are  in  good  condition,  in 
order  that  the  food  may  be  properly  masticated. 

When  the  patient  is  taking  three  meals  daily,  and  for  any 
reason  it  seems  advisable  further  to  supplement  the  diet,  if  it 
is  impossible  for  them  to  take  milk,  beef-juice  may  be  given 
between  meals,  or  even  scraped  beef.  Most  patients  do  not 
object  to  beef-juice  if  the  meat  is  slightly  broiled,  quickly  cut 
up,  and  placed  in  a  press  which  has  been  heated,   and  the 


PULMONARY    TUBERCULOSIS.  421 

receptacle  also  warmed,  the  juice  being  consumed  before  it 
has  cooled.  They  seem  to  prefer  it  warm,  and  it  is  extremely 
difficult  to  warm  the  juice  up  afterward  without  precipitating 
the  albumen,  unless  this  is  done  upon  a  water  bath.  Some 
prefer  the  juice  of  the  raw  meat  and  the  raw  scraped  beef, 
which  may  be  given  properly  seasoned  in  the  form  of  a  canni- 
bal sandwich,  on  thin  stale  or  toasted  bread.  A  point  usually 
overlooked  in  the  making  up  of  a  dietary  is  that  as  much 
variety  as  possible  has  a  distinct  advantage,  (monotony  being 
one  of  the  serious  objections  to  the  tnilk-and-egg  diet),  as  has 
also  the  flavor  and  careful  preparation  of  the  food.  No  detail 
is  too  insignificant  in  the  ordering  of  the  daily  menu,  and  this 
subject  should  receive  the  closest  attention  of  the  attending 
physician.  Frequently  it  will  be  found  necessary  to  experi- 
ment with  various  varieties  of  foodstuffs  before  a  dietary  can 
be  obtained  which  creates  a  gain  of  weight.  Even  when  the 
full  milk-and-egg  diet  is  contraindicated,  it  will  be  frequently 
found  that  one  or  two  glasses  of  milk  can  be  taken  with  each 
meal,  and  this,  of  course,  adds  considerably  to  the  daily 
amount  of  nutritive  material  consumed. 

A  point  frequently  overlooked  in  treating  cases  of  pul- 
monary tuberculosis  is  that  in  the  early  cases  only  sufficient 
food  should  be  given  to  assure  a  steady  gain  of  weight.  It  is 
a  mistake  to  try  to  force  the  feeding  in  those  cases,  in  order 
merely  to  see  how  much  can  be  gained  in  a  short  time.  While 
a  rapid  gain  in  weight  is  very  encouraging  to  the  patient,  it  is 
frequently  acquired  at  too  high  a  cost,  with  a  sacrifice  of  the 
-future  gastric  power  as  a  result.  The  natural  method  of  eat- 
ing for  most  people  consists  of  taking  three  meals  a  day,  as  the 
stomach  has  been  accustomed  to  receiving  food  of  a  certain 
kind  at  fixed  intervals.  No  matter  what  method  of  dieting  is 
pursued  in  the  early  part  of  the  treatment,  the  main  object  to 
be  kept  in  view  is  to  get  the  patient  back  to  three  meals  a  day, 
and  to  have  him  hold  or  gain  his  weight  upon  such  a  diet. 

The  more  advanced  cases  present  a  somewhat  different 
problem,  and  it  is  in  such  that  forced  feeding,  when  given  with 
judgment  and  careful  supervision,  is  more  permissible.  The 
immediate  need  of  increased  nutrition  in  these  cases  warrants 
one  in  insisting  upon  their  taking  food  in  excess  of  their 
desire. 


422  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Children  suffering  from  tuberculosis  do  not,  as  a  rule,  take 
kindly  to  the  milk-and-egg  diet,  although  it  should  always  be 
given  a  careful  trial  before  being  abandoned.  In  cases  of  this 
age-period  three  meals  a  day  will  usually  be  found  most  satis- 
factory, especially  when  cod-liver  oil  is  given  in  addition. 
They  will  frequently  take  the  oil  in  the  form  of  an  emulsion 
without  the  slightest  trouble,  when  it  is  impossible  to  make 
them  take  an  increased  quantity  of  food,  and  generally  they 
do  very  well  on  this  addition  to  their  diet,  and  in  consequence 
usually  gain  steadily  in  weight. 

Hydrotherapy.  In  the  treatment  of  a  prolonged  illness, 
such  as  is  usually  the  rule  in  pulmonary  tuberculosis,  no 
means  must  be  neglected  to  improve  the  general  tone  of  the 
patient,  especially  such  measures  as  are  unaccompanied  by 
an}'-  dangerous  after-results  or  risks  of  harm.  The  application 
to  the  skin  of  water  of  varsnng  temperature  has  long  been  one 
of  the  most  popular  and  accessible  measures  for  combating 
disease,  and  in  certain  conditions  it  has  attained  considerable 
and  richh'  deserved  reputation.  In  the  treatment  of  all  cases 
of  tuberculosis  the  external  application  of  water  will  prove  of 
unquestionable  value.  It  is  not  necessar}^  to  have  the  com- 
plicated apparatus  of  the  hydropathic. institution  in  order  to 
secure  favorable  results.  In  early  cases  a  cold  chest-bath  in 
the  morning  on  arising  usually  gives  the  patient  a  sense  of 
stimulation  that  cannot  be  obtained  in  any  other  w^ay.  In  cold 
weather  it  is  necessary  for  the  patient  to  have  a  w^arm  room 
in  which  to  carr}-  out  this  procedure,  and  it  should  always  be 
followed  by  a  brisk  rub  wnth  a  rough  towel.  Some  cases  find 
the  chest-bath  insufficient,  in  which  case  a  general  cool  sponge 
or  shower  may  be  substituted,  colder  water  being  gradually 
applied  until  the  desired  eft'ect  is  obtained.  It  is  necessary  to 
caution  patients  against  taking  baths  with  water  that  is  too 
cold,  and  to  warn  them  against  unduly  prolonging  the  applica- 
tion. The  bath  should  be  absolutely  forbidden,  if  it  is  not 
followed  by  a  definite  reaction,  with  a  general  glow  and  sense 
of  well-being.  If  the  patient  fails  to  react,  and  feels  chilled 
for  any  period  after  the  baths,  they  must  be  discon- 
tinued. Nearly  everyone,  however,  can  take  the  cold  chest- 
bath  with  benefit,  if  care  is  exercised  in  the  method  of 
application. 


PULMONARY    TUBERCULOSIS.  423 

The  use  of  cool  or  cold  sponges  in  the  cases  with  excessive 
elevation  of  temperature  is  discussed  elsewhere,  also  their  em- 
ployment in  preventing  night-sweats.     (See  pp.  456-7  and  458.) 

For  a  patient  with  afternoon  fever  and  a  subnormal  morn- 
ing temperature,  one  must  be  especially  careful  in  using  cold 
baths  in  the  morning.  The  majority  of  patients  with  this  type 
of  temperature  obtain  more  comfort  from  a  warm  bath  in  the 
morning.  The  temperature  of  the  water  used  for  the  morning 
bath  may  from  day  to  day  be  gradually  lowered  until  finally  a 
cool  bath  may  be  employed,  but,  as  previously  stated,  it  should 
be  discontinued  on  the  slightest  evidence  of  chilling. 

For  general  purposes  of  cleanliness,  the  ambulant  patient 
may  be  permitted  to  use  the  tub  two  or  three  times  a  week. 
The  water  should  be  comfortably  warm,  not  excessively  hot, 
and  should  always  be  followed  by  a  cool  or  cold  sponge.  Only 
rarely  should  the  bed  patient  be  bathed  in  the  tub ;  in  most 
instances  it  is  advisable  to  have  it  done  in  bed  between 
blankets,  and  one  extremity  at  a  time  being  bathed,  followed 
by  bathing  of  the  trunk,  with  not  too  much  of  the  body  being 
exposed  at  any  one  time. 

The  convalescent  patient  will  occasionally  ask  for  advice 
in  regard  to  ocean  or  surf  bathing  in  the  summer  time.  While 
a  quick  bath  in  the  salt  water  would  probably  prove  of  value, 
the  discomforts  usually  attending  this  form  of  bathing,  the 
temptation  to  remain  in  the  water  longer  than  advisable,  and 
the  fatigue  from  resisting  the  force  of  the  waves,  more  than 
counterbalance  any  benefit  that  might  be  derived  from  it. 
When  the  patient  has  reached  the  point  where  it  is  possible  for 
the  physician  to  consider  him  an  absolute  cure,  say,  after  the 
disease  has  been  arrested  for  two  or  three  years,  this  form 
of  diversion  may  be  practised,  provided  that  every  precaution 
is  observed  to  prevent  prolonged  chilling  and  over-fatigue. 

Artificial  Pneumothorax.  During  recent  years  this  method 
of  treating  pulmonary  tuberculosis  has  been  extensively  ap- 
plied, and  the  results  carefully  recorded  and  studied.  Theo- 
retically, this  placing  of  the  lung  at  absolute  rest  should  be 
followed  by  arrest  of  the  process  in  the  large  majority  of  cases, 
but  unfortunately  in  practice  this  is  not  the  case,  the  main 
reason  being  that  only  a  small  proportion  of  the  cases  in  which 
it  is  tried  are  suitable  for  this  method  of  treatment.    The  sue- 


424  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

cess  following  the  production  of  the  artificial  pneumothorax 
will  be  directly  proportionate  to  the  care  and  judgment  exer- 
cised in  the  selection  of  cases  in  which  it  is  induced,  as  the 
majority  of  observers  believe  that  only  about  5  per  cent,  of 
all  cases  are  suitable  for  this  form  of  treatment,  and  it  is  a 
procedure  that  is  not  without  certain  disadvantages  and  risks. 
The  injections  must  be  kept  up  for  a  long  period  of  time,  dur- 
ing which  the  patient  should  be  kept  under  absolute  control, 
preferabty  in  a  sanatorium,  making  it  an  expensive  and  tedious 
method  of  treatment.  The  dangers  of  air  embolism,  pleural 
shock,  subcutaneous  emphysema,  and  injury  to  the  lung,  while 
probably  more  theoretical  than  real,  cannot  be  ignored,  as  the 
procedure  possesses  a  slight  mortalit}^  due  to  the  injections. 
This  is  a  truth  to  be  taken  into  account  when  considering  the 
advisability  of  instituting  this  method  of  treatment. 

The  development  during  the  treatment  of  serous  efifu- 
sions,  which  ma}^  later  become  purulent,  is  of  relatively  fre- 
quent occurrence,  and  constitutes  a  very  grave  complication 
which  may  arise  in  the  course  of  the  treatment  in  au}^  patient, 
and  appears  to  bear  no  relation  to  the  care  exercised  in  making 
the  injections.  Taking  everything  into  consideration,  it  seems 
that  this  procedure  should  be  resorted  to  only  in  those  pa- 
tients who  Have  failed  to  respond  to  general  hygienic  treat- 
ment, in  whom  the  rapidity  with  which  the  disease  spreads 
renders  delay  dangerous,  or  in  whom  there  is  some  special 
indication  such  as  hemoptysis.  Only  those  cases  are  suitable 
for  treatment  which  present  certain  generally  accepted  indica- 
tions, a  list  of  which  is  given  by  Sloan,  as  follows : 

"(a)  Gross  and  active  lesions  in  one  lung,  with  a  quiescent 
lesion  not  extending  below  the  level  of  the  fourth  rib  in  the 
other  lung;  (b)  gross  and  active  lesions  in  one  lung,  with  a 
mildty  active  lesion  not  extending  below  the  level  of  the  third 
rib  in  the  other;  (c)  quiescent  lesions,  bilateral,  but  suitably 
located,  with  a  history  of  aggravating  cough  and  profuse  ex- 
pectoration; (d)  arrested  but  suitably  located  lesions,  with  a 
previous  history  of  collapse  whenever  work  was  attempted ; 
(e)  arrested  lesions,  but  with  a  history  of  recurring  hemor- 
rhages." He  considers  as  unsuitable  all  cases  showing:  "(a) 
Gross  and  active  lesions  extending  below  the  level  of  the  third 
rib  on  both  sides;  (b)  an  extensive  gross  lesion  in  one  lung, 


PULMONARY   TUBERCULOSIS.  425 

and  a  lesion  located  at  the  base  in  the  other;  (c)  serious  com- 
plications, such  as  cardiac  disease,  arteriosclerosis,  ulcerative 
laryngitis,  chronic  diarrhea,  extensive  tuberculous  ostitis,  and 
nephritis,  acute  or  chronic;  (d)  disease  apparently  of  long 
standing,  as  shown  by  marked  fibrosis  of  the  lungs,  thoracic 
deformities,  decided  cardiac  displacement  and  dyspnea;  (e)  a 
history  of  chronic  alcoholism ;  (/)  a  history  of  recurring  hemor- 
rhages from  both  lungs;  (g)  a  marked  emphysema;  (h)  an 
erratic  or  excitable  temperament;  (i)  real  or  apparent  old  age." 

It  will  be  noted  that  he  advocates  employing  this  method 
in  cases  in  which  the  disease  is  bilateral;  and  while  he  is 
supported  in  this  opinion  by  many  careful  observers,  the 
writer  cannot  help  but  feel  that  from  a  theoretical  standpoint 
bilateral  disease  should  be  considered  as  a  contraindication,  a 
view  which  a  limited  experience  in  the  employment  of  this 
procedure  has  tended  to  confirm.  If  ever  employed  in  a  case 
of  bilateral  disease,  the  uncompressed  side  certainly  should 
be  most  carefully  watched  for  any  evidence  of  increased 
activity.  The  ideal  case  for  treatment  by  this  method  would 
be  a  patient  with  an  acute  unilateral  tuberculosis,  tending  to 
extend  or  to  show  no  signs  of  becoming  arrested  under  careful 
general  treatment;  in  addition,  there  should  be  no  complica- 
tions, and  the  disease  must  be  so  limited  as  to  warrant  the 
persistence  of  a  fair  area  of  air-bearing  lung  tissue.  It  must 
be  confessed  that  such  cases  are  not  commonly  encountered. 
At  times  it  may  be  justifiable  to  employ  this  method  of  therapy 
in  certain  advanced  cases,  with  the  object  of  ameliorating  the 
symptoms  and  securing  additional  comfort  for  the  patient, 
without  any  thought  of  arresting  the  disease. 

The  immediate  results  of  this  treatment  are  usually  very 
good,  and  at  times  almost  miraculous,  transforming  within  a 
few  days  a  patient  with  a  high  fever,  profuse  expectoration, 
poor  appetite,  and  digestive  disturbances,  in  whom  the  dis- 
ease is  steadily  progressing,  into  one  who  has  no  fever,  or 
very  slight  pyrexia,  very  little  expectoration,  a  good  appetite, 
no  gastric  disturbances,  and  a  general  sense  of  well-being  and 
comfort.  While  usually  the  injections  are  very  well  borne, 
occasionally  the  injection  of  the  nitrogen  gas  into  the  pleural 
space  is  followed  by  dyspnea,  considerable  general  distress, 
and  severe  pains  lasting  several  hours. 


426  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

The  ultimate  results  are  not  so  encouraging,  even  in 
selected  cases,  for  the  majority  of  writers  report  ultimate 
recoveries  in  only  about  50  per  cent,  of  the  cases.  It  will  thus 
be  seen  that,  while  of  considerable  value  for  ameliorating  the 
symptoms  in  certain  advanced  cases,  as  a  method  for  curing 
the  disease  it  is  a  procedure  whose  field  of  application  is  dis- 
tinctly limited. 

Technic:  It  is  impossible  to  describe  in  detail  the  various 
methods  employed  for  inducing  artificial  pneumothorax  by 
means  of  the  introduction  of  nitrogen  gas  into  the  pleural 
space,  nearly  every  writer  on  the  subject  having  detailed  cer- 
tain minor  modifications  in  the  technic.  The  technic,  in  a 
ver}-  general  w^ay,  includes  anesthetization  of  the  skin,  sub- 
cutaneous tissue  and  pleura  by  a  deep  injection  of  novocain, 
after  sterilization  of  the  skin  with  tincture  of  iodin,  usually 
in  the  mid-axillary  line  at  about  the  level  of  the  fourth  or  fifth 
interspace,  although  at  times  it  may  be  found  .necessary  to 
make  the  injection  further  posteriorly,  at  a  lower  level.  The 
skin  is  then  incised  with  a  sharp,  thin-bladed  (cataract)  knife, 
and  the  blunt  Floj^d  needle,  connected  with  a  water  manom- 
eter, is  inserted  into  the  pleural  space.  After  having  secured 
a  partial  or  complete  collapse  of  the  lung,  in  making  the  sub- 
sequent reinsuffl-ations  it  may  not  be  necessary  to  make  an 
incision  and  use  the  blunt  needle,  the  injections  being  made 
by  puncturing  with  an  ordinary  aspirating  needle.  The 
greatest  care  must  be  exercised  to  avoid  infecting  the  pleura, 
by  using  every  precaution  to  perform  the  operation  in  a  thor- 
oughly aseptic  manner.  As  soon  as  the  entrance  to  the  pleural 
space  has  been  accomplished,  a  fluctuation  in  the  water 
manometer  is  obtained,  ranging  between  negative  2  cm.  and 
negative  4  cm.  W^here  numerous  dense  adhesions  exist,  the 
fluctuation  may  be  very  slight,  or  it  may  be  impossible  to 
obtain  any  fluctuation  at  all.  No  gas  should  be  inserted  unless 
the  proper  fluctuation  has  been  obtained.  AMien  the  ad- 
hesions cover  only  a  moderate  proportion  of  the  pleural  sur- 
face, repeated  injections  may  be  followed  b}-  the  drawing  out 
of  the  adhesions  to  form  connective  tissue  bands  transversing 
the  pleural  space,  which  eventually  ma}^  permit  the  lung  to 
collapse  completely.  The  warm,  filtered  nitrogen  gas  or 
atmospheric  air  may  be  injected  slowly  at  the  rate  of  about 


PULMONARY   TUBERCULOSIS. 


427 


100  mils  per  minute  until  500  or  600  mils  have  been  intro- 
duced, provided  that  no  symptoms  arise  to  contraindicate  the 
further  injection  of  the  g-as,  such  as  severe  pain,  cough,  dis- 
tress, sense  of  tightness,  or  shock ;  and  on  withdrawing-  the 
needle  the  opening'  in  the  skin  should  be  sealed.  It  is  advis- 
able to  control  the  injection  by  taking  manometric  readings 
after  every  100  mils  of  gas  have  been  injected,  ceasing  the 
introduction  of  the  gas  wheu  slight  positive  pressure  (4-6 
mils)  has  been  obtained,  or  500  or  600  mils  have  been  injected. 
In  injecting  the  gas  it  is  important  to  avoid  using  an  excessive 
amount  of  pressure,  and  in  the  majority  of  cases  no  pressure 


Fig.  18.- — Apparatus  for  inducing  artificial  pneumothorax.  At- 
tached to  the  rear  upright,  on  the  reader's  left,  is  the  water  mano- 
meter for  determining  the  intrapleural  pressure. 

at  all  is  required.  Some  writers  recommend  a  larger  quantity 
of  gas  when  reinsufflation  is  performed,  even  up  to  1000  mils 
at  times  being  injected,  these  reinsufflations  being  recom- 
mended at  first  every  other  day,  then  twice  a  week,  once  a 
week,  once  in  two  weeks,  until  an  effective  collapse  has  been 
obtained,  and  then  only  once  a  month,  or  at  even  longer  inter- 
vals. There  seems  to  be  no  uniformity  of  opinion  as  to  when 
the  injections  may  be  discontinued,  but  all  agree  on  the  impor- 
tance of  studying  the  cases  carefully  by  means  of  frequent 
physical  examinations  and  repeated  skiagrams.  The  presence 
of  fluid,  when  only  slight  in  amount,  seems  to  be  most  accu- 
rately determined  by  skiagTaphy. 


428  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

Nitrogen  gas  was  employed  originally  in. making  the  injec- 
tions because  it  was  believed  that  it  was  not  so  rapidly  ab- 
sorbed by  the  pleural  surface.  During  more  recent  years 
sterile,  warm  atmospheric  air  is  being  more  extensively  used, 
as  it  tends  to  simplify  the  operation,  and  because  it  has  been 
shown  that  there  is  very  little  difference  between  the  diffus- 
ibility  of  nitrogen  and  atmospheric  air. 

Whenever  suggesting  the  employment  of  the  artificial 
pneumothorax  to  a  patient^  it  is  advisable  to  explain  in  a  gen- 
eral way  the  theory  upon  which  it  is  based,  the  chances  of 
favorable  results,  and  the  advantages  and  disadvantages 
attending  its  use.  Nothing  could  be  more  unwise  than  to  urge 
the  employment  of  such  a  method  of  treatment  even  in  cases 
in  which  it  seems  to  be  specially  indicated,  without  first  sup- 
plying the  patient  with  such  information  that  it  may  be  pos- 
sible for  him  to  decide  for  himself  as  to  whether  it  should  be 
used  or  not. 

Some  clinicians  have  attempted  to  secure  an  efifect  similar 
to  that  obtained  by  artificial  pneumothorax  by  insisting  upon 
the  patients  lying  as  much  as  possible  on  the  afifected  side. 
Whenever  possible,  it  would  appear  advantageous  to  encour- 
age the  patient  to  sleep  upon  the  afifected  side  in  order  thereby 
to  limit  the  expansion  of  that  side.  The  same  conditions  are 
secured  by  strapping  the  affected  side  of  the  chest,  a  method 
which  may  be  employed  with  advantage  in  selected  cases. 
Certain  patients  are  unable  to  sleep  on  the  affected  side  on 
account  of  the  constant  cough  which  attends  any  effort  to 
maintain  such  a  position.  The  straps  are  also  exceedingly 
disturbing,  on  account  of  the  sense  of  oppression  which  occa- 
sionally follows  their  use,  and  because  of  the  irritation  of  the 
skin  which  may  result  from  a  prolonged  application  of  the 
adhesive  plaster. 

SPECIFIC    TREATMENT. 

Medicinal.  The!  medicinal  treatment  of  pulmonary  tubercu- 
losis consists  mainly  of  the  correction  of  certain  symptoms  or 
complications,  as  the  drugs  which  have  been  credited  with 
specific  value  in  the  treatment  of  the  tuberculous  process  have 
proven  far  from  satisfactory.  The  majority  of  patients  do 
best  when  the  amount  of  medicine  taken  is  kept  down  to  the 


PULMONARY    TUBERCULOSIS.  429 

smallest  quantity  possible.-  Numerous  drugs  from  time  to 
time  have  been  lauded  as  specifics  in  this  disease,  but  the  fact 
that  they  have  been  discarded  as  useless  serves  to  show  how 
little  real  value  they  possessed.  Arsenic,  phosphorus,  mer- 
cury, cinnamic  acid,  ichthyol,  iodoform,  menthol,  eucalyptol, 
and  numerous  other  drugs  have  been  recommended  in  the 
past  as  of  value  in  the  treatment  of  this  disease,  but  further 
experience  proved  their  lack  of  specific  value.  It  is  to  be 
hoped  that  some  of  the  systematic  investigations  now  under 
way  ultimately  will  develop  some  combination  of  chemical 
ag'ents  which  may  prove  efficacious  in  the  treatment  of  this 
disease. 

Before  considering  the  treatment  of  the  various  symptoms 
and  complications  of  this  disease,  it  might  be  of  interest  to 
give  some  consideration  to  a  drug  which  has  been  considered 
of  benefit  in  the  treatment  of  this  disease,  although  in  recent 
years  it  has  been  somewhat  discredited. 

Alcohol.  The  use  of  alcohol  at  one  time  was  held  to  possess 
a  value  in  treating  tuberculosis  which  was  considered  almost 
specific.  It  is  fortunate  that  the  "barrel  of  whiskey  and  a  bar- 
rel of  cod-liver  oil  in  the  wilderness"  method  of  treating  the 
disease  never  received  a  very  general  acceptance  over  any 
considerable  period  of  time.  The  effect  of  this  teaching  is 
still  felt,  however,  and  it  is  not  an  uncommon  practice,  even 
at  the  present  time,  to  add  alcohol  to  the  dietary  or  medication 
of  tuberculous  cases.  While  the  addition  of  alcohol  in  the 
form  of  whiskey  may  occasionally  prove  of  value  in  the  treat- 
ment of  acute  conditions  arising  during  the  course  of  the 
chronic  forms  of  tuberculosis,  it  should  always  be  combined 
with  other  drugs,  being  given  as  a  medicine  and  never  per- 
mitted as  a  beverage.  The  continued  use  of  alcohol  must  be 
considered  a  very  serious  detriment  in  practically  ever}^  case, 
and  it  should  never  be  employed  except  to  meet  some  distinct 
indication,  and  then  discontinued  as  soon  as  possible. 

There  are  several  serious  objections  to  the  use  of  alcohol, 
aside  from  any  deleterious  effect  it  may  or  may  not  possess 
upon  the  resistance  of  the  individual.  In  the  first  place,  the 
use  of  alcohol  by  the  patient  himself  in  the  early  stages  of 
the  disease  will  not  infrequently  permit  him  to  continue  his 
ordinary  occupation  for  a  longer  period  than  it  would  be  pos- 


430  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

sible  for  him  to  do  without  its  use.  Thus,  not  infrequently, 
the  patient  is  finally  obliged  to  discontinue  his  work  and  to 
come  under  a  physician's  care  at  a  period  when  the  disease 
has  made  such  inroads  as  to  be  practically  incurable,  instead 
of  at  that  early  stage  when  the  results  of  treatment  are  best. 
The  abuse  of  alcohol  is  responsible  in  many  instances  for 
the  patient's  losing  the  possibility  of  an  arrest  of  the  process, 
with  the  functionating  power  of  the  lung  almost  fully  pre- 
served. 

The  objections  to  its  use  during  treatment  is  that  it  gives 
a  false  sense  of  well-being  and  strength,  usually  resulting  in 
overexertion  and  fatigue  directly  due  to  the  fictitious  feeling 
of  strength  created  by  this  drug.  The  chief  objection  to  its 
use  is  that  in  a  chronic  disease  of  this  kind,  where  the  treat- 
ment is  almost  certain  to  be  long  drawn  out  and  tedious,  we 
have  need  of  all  t)iQ  moral  stamina  which  the  patient  pos- 
sesses to  adhere  to  the  rather  rigid  regulations  necessary  for 
an  arrest  of  the  process.  The  "moral  anesthetic"  efifect  of  this 
drug,  or  its  ability  to  destroy  the  will-power  of  the  individual, 
must  be  considered  its  greatest  and  most  serious  drawback. 

Tuberculins  and  Sera.  Since  the  use  oi  tuberculin  was  first 
suggested  in  the  treatment  of  tuberculosis  there  have  been 
innumerable  preparations  recommended,  their  claim  for 
originality  and  virtue  depending  upon  variations  in  the 
technic  of  manufacture,  upon  the  source  of  the  bacilli,  the 
portion  of  the  culture  used,  and  similar  details.  The  mere 
fact  that  so  many  different  kinds  of  tuberculin  have  been 
recommended  would  indicate  that  the  results  following  its 
employment  have  been  far  from  satisfactory.  It  may  be 
stated  that  at  the  present  time  there  are  very  few  experienced 
clinicians  outside  of  large  private  sanatoria  who  emplo}^  tuber- 
culin or  recommend  its  use  in  the  treatment  of  pulmonary 
tuberculosis.  That  it  possesses  distinct  possibilities  for  harm 
is  generally  acknowledged,  and  every  observer  urges  the 
necessity  of  extreme  caution  in  its  administration.  While 
favorable  results  are  occasionally  reported  from  its  use,  espe- 
cially in  surgical  and  localized  tuberculosis,  the  reports  based 
upon  its  use  in  pulmonary  tuberculosis,  when  viewed  impar- 
tially, cannot  be  said  to  be  xerj  convincing  when  the  results 
are  compared  with  those  obtained  when  it  has  not  been  em- 


PULMONARY    TUBERCULOSIS.  431 

ployed,  and  the  same  statement  can  be  made  in  regard  to  the 
various  sera  which  have  been  recommended  in  the  treatment 
of  this  disease. 

The  more  one  studies  the  various  agents  suggested  as  pos- 
sessing- value  of  a  specific  character  in  the  treatment  of  tuber- 
culosis, the  more  one  is  impressed  with  the  importance  of 
availing  oneself  of  the  various  measures  we  possess  for  in- 
creasing the  resistance  of  the  individual  by  improving  their 
general  health.  At  the  same  time  further  study  and  investi- 
gation, both  clinical  and  laboratory,  should  be  directed  toward 
the  development  of  a  therapeutic  agent  which  will  possess  a 
definite  specific  action  upon  the  tuberculous  process,  as  it  is 
impossible  to  estimate  the  enormous  effect  upon  the  general 
health  of  the  community,  with  all  its  widespread  influence 
upon  economic  and  social  conditions,  which  would  result  from 
the  possession  of  an  agent  which  would  do  for  tuberculosis 
what  salvarsan  has  done  for  syphilis.  It  has  been  proved 
beyond  question  that  tuberculous  subjects  are  especially  sus- 
ceptible to  suggestion,  and  probably  the  psychic  influence  of 
tuberculin  treatment  is  largely  responsible  for  what  favorable 
results  have  followed  its  use.  A  very  serious  objection  to 
the  use  of  tuberculin  is  that  we  possess  no  ready  method  for 
estimating  the  toxicity  of  any  preparation,  for  even  when 
made  by  the  identical  method  they  may  vary  greatly.  One 
may  readily  see  that  it  is  impossible  to  lay  down  any  fixed 
rules  as  to  dosage  or  frequency  of  administration. 

The  numerous  preparations  of  tuberculin  fall  into  three 
large  groups:  (1)  those  composed  of  toxins  produced  by  the 
tubercle  bacilli  in  artificial  culture  media,  like  Koch's  old 
tuberculin  (O.  T.)  ;  (2)  those  containing  the  tubercle  bacilli 
themselves  or  their  endotoxins,  like  Koch's  bacillary  emul- 
sions (B.  E.)  ;  and  (3)  a  combination  of  (1)  and  (2).  like  T.  R. 
As  the  effect  of  any  tuberculin  when  injected  into  the  bod}^  is 
apparently  the  same,  it  does  not  appear  as  if  it  made  any 
difference  which  type  of  tuberculin  was  employed.  It  has 
been  recommended  that  tuberculins  of  the  type  1  of  old  tuber- 
culin should  be  employed  in  those  cases  in  which  the  evi- 
dence of  general  toxemia  was  out  of  all  proportion  to  the 
degree  of  activity  of  the  pulmonary  lesion,  as  determined  by 
physical  examination,  and  type  2  tuberculins  should  be  em- 


432  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

ployed  in  those  cases  in  which  the  pulmonary  invasion  was 
especially  marked,  with  only  relatively  slight  evidence  of  gen- 
eral toxemia;  type  3  tuberculins  being  used  in  the  cases  in 
which  the  two  processes  were  apparently  equal. 

The  dilution  of  the  tuberculin  should  be  made  with  dis- 
tilled water  or  0.8  per  cent,  salt  solution  to  which  has  been 
added  0.5  per  cent,  of  carbolic  acid,  and  it  is  advisable  to  use 
onty  freshly  diluted  tuberculin.  For  diluting  the  tuberculin 
one  should  have  six  to  ten  amber  colored  bottles,  clean  and 
sterile,  labeled  I,  II,  III,  etc.  In  bottle  I  is  placed  0.1  mil  of 
tuberculin  to  be  employed  and  9.9  mils  of  the  diluent.  Each 
mil  of  this  bottle  will  therefore  contain  0.01  mil  or  10  c.mm. 
of  tuberculin.  In  each  of  the  remaining  bottles  is  placed  9 
mils  of  diluent.  One  mil  from  bottle  I  is  then  placed  in  bottle 
II,  each  mil  of  which  will  then  contain  1  c.mm.  of  tuberculin. 
When  1  mil  of  II  solution  is  placed  in  bottle  III,  the  latter 
will  contain  0.1  c.mm.  of  tuberculin  in  each  mil  of  solution. 
Bv  continuing  this  process  each  mil  of  bottle  IV  will  con- 
tain 0.01  c.mm.  of  tuberculin;  of  bottle  V.  0.001  c.mm.  tuber- 
culin; of  bottle  VI  0.0001  c.mm.  tuberculin;  and  each  mil 
of  bottle  \^II  will  contain  0.00001  c.mm.  of  tuberculin. 
This  process  may  be  continued  until  finally  a  dilution  is 
reached  where  each  mil  will  equal  ten  times  the  desired  initial 
dose. 

The  initial  dose  will  be  0.1  mil  of  the  selected  dilution, 
which  may  be  continued  indefinitely  or  gradually  increased. 
In  increasing  the  dose  it  has  been  suggested  that  it  be  not 
increased  by  0.1  mil  each  time,  as  that  doubles  the  original 
dose  the  first  time  it  is  increased,  the  proportionate  increase 
in  the  dosage  gradually  diminishing  as  one  approaches  the 
full  mil.  It  has  been  recommended  that  the  dose  be  increased 
by  }4  each  time,  which  would  give  a  dose  increase  approxi- 
mately as  follows:  0.1  mil.  0.12  mil,  0.15  mil,  0.19  mil,  0.24 
mil,  6.30  mil,  0.37  mil,  0.46  mil,  0.57  mil,  0.71,  mil,  0.89  mil, 
and  1.1  mil,  or  0.11  of  the  bottle  with  the  next  lower  number. 
It  is  advisable  to  keep  the  amount  of  fluid  about  1  mil  or  less, 
in  order  to  avoid  injecting  too  large  a  quantity"  under  the  skin 
at  one  time.  The  injections  may  be  made  in  the  arm  or  back, 
the  latter  being  the  preferable  location,  but  having  the  objec- 
tion of  being  less  accessible. 


PULMONARY    TUBERCULOSIS.  433 

The  initial  doses  recommended  range  anywhere  between 
1  mg^.  and  0.0000005  mg.,  the  latter  being-  preferable  because 
least  likely  to  do  harm.  Systemic  reactions  should  be  avoided 
by  exercising  great  care  in  increasing  the  dose,  but  occasion- 
ally they  appear'  to  be  unavoidable.  In  the  event  of  a  re- 
action, the  succeeding  doge  should  be  well  below  the  amount 
first  given,  and  the  same  dose  continued  for  some  time  before 
being  increased,  or  the  dose  should  be  increased  very  grad- 
ually. The  intervals  between  doses  should  be  about  two  or 
three  days  in  length,  the  treatment  being  continued  until  a 
point  is  reached  where  it  appears  desiral)le  to  discontinue  for 
some  reason  or  other.  The  various  advocates  of  tuberculin 
are  far  from  being  unanimous  in  their  opinion  as  to  when  the 
dose  should  not  be  further  increased,  or  the  treatment  dis- 
continued. 

Tuberculin  treatment  should  never  be  emplo3'ed  in  tlie 
actively  progressing  forms  of  pulmonary  tuberculosis,  when 
there  is  evidence  of  marked  activity,  or  in  cases  with  distinct 
cardiac  or  renal  disease.  The  least  indication  of  increasing 
activity  in  the  pulmonary  process  should  be  a  warning  that 
the  administration  of  tuberculin  should  be  discontinued. 

DISPENSARY    TREATMENT. 

Tuberculosis  is  very  prevalent  among'  many  persons  who 
are  unable  to  receive  proper  medical  attention  for  economic 
reasons.  In  the  large  cities  it  is  quite  a  problem  to  deter- 
mine how  these  destitute  individuals  may  be  taken  care  of 
most  efficiently  and  economically.  It  Is  generally  recog- 
nized that  sanatorium  or  hospital  treatment  is  the  best  method 
for  patients  during  the  active  and  advanced  stages  of  the 
disease  (as  discussed  in  the  section  on  General  Considera- 
tions, p.  406),  and  this  leaves  a  large  group  for  whom  sana- 
torium and  hospital  treatment  is  either  unnecessary  or 
impossible.  Those  who  are  unable  to  pay  for  medical  at- 
tendance and  require  home  treatment  are  best  managed  by 
the  dispensary  service,  for  numerous  reasons.  In  establishing 
dispensaries  it  is  important  that  provision  be  made  for  clinics 
whose  sole  function  shall  be  the  treatment  of  tuberculosis,  and 
that  the  dispensaries  be  so  located  that  they  will  be  easy  of 
access,  and  that  the  districts  covered  by  each  dispensary  will 


434  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

not  overlap.  It  is  equally  important  that  the  dispensary  con- 
fines its  work  to  its  immediate  neighborhood,  so  that  the  home 
visitation  can  be  most  effectively  performed. 

The  cases  suitable  for  dispensary  treatment  are:  (1)  those 
who  have  had  the  disease  sufficiently  arrested  to  warrant  their 
returning  to  work,  but  who  still  need  to  be  kept  under  obser- 
vation to  prevent  a  recurrence ;  (2)  that  large  group  in  whom 
the  disease  runs  a  very  quiet,  chronic  course,  which  interferes 
very  little  with  their  general  health ;  (3)  children  who  show 
evidence  of  infection,  and  whose  general  health  is  so  poor  as 
to  warrant  fears  that  the  disease  may  become  active ;  (4)  a 
small  group  in  which  the  disease  is  active,  but  for  various 
reasons  it  is  deemed  advisable  to  retain  in  their  own  home. 
With  these  groups  of  cases  alone  the  dispensary  should  deal. 

The  dispensary  which  is  fulfilling  its  duty  in  a  thorough 
and  efficient  manner  should  not  stop  with  merely  treating 
patients,  but  should  perform  other  equally  important  func- 
tions. The  object  of  the  dispensary  should  be  the  detection 
of  the  disease  in  its  earliest  stages,  by  attracting  patients  by 
every  possible  means,  and  by  the  examination  of  the  other 
members  of  the  family  of  every  patient  attending  the  dispen- 
sary, whenever  this  is  possible.  It  should  also  act  as  a 
medium  for  educating  the  patients,  their  families,  and  their 
friends  in  the  means  of  prevention  of  the  disease  and  also  in 
the  value  of  ordinary  hygiene  and  proper  living.  The  hold 
upon  the  patient  should  also  serve  as  a  means  of  insisting 
upon  their  carrying  out  the  necessary  preventive  measures,  the 
visitation  of  the  homes  helping  to  insure  that  they  are  prop- 
erly and  thoroughly  carried  out.  Finally,  the  work  of  the 
dispensary  should  be  carefully  and  accurately  recorded,  so 
that  the  material  collected  may  be  available  for  analysis  and 
study.  The  investigation  of  such  important  problems  as  are 
connected  with  housing,  workshops,  infection,  and  so  forth 
should  be  an  important  part  of  the  dispensary's  paper  work. 

It  is  impossible  to  describe  in  detail  the  manner  in  which 
the  work  of  prevention,  education,  and  investigation  can  be 
best  carried  out,  but  the  treatment  of  these  dispensary  cases 
is  sufficiently  important  to  warrant  its  being  described  at  some 
length.  For  the  first  examination  in  all  cases  it  is  best  to 
have  a  personal  consultation  between  the  physician  and  the 


PULMONARY    TUBERCULOSIS.  435 

patient.  The  large  proportion  of  the  patients  can  be  treated 
in  a  more  satisfactory  manner  by  what  is  known  as  the  "class 
method"  as  evolved  by  Dr.  Pratt.  This  method  of  treatment 
consists  of  holding-  conferences  with  the  patients  once  every 
Viieek  or  two  weeks,  at  which  a  talk  is  given  by  the  physician 
in  charge  upon  various  topics  connected  with  the  subject  of 
tuberculosis.  These  talks  should  cover  such  subjects  as  rest 
and  exercise,  diet,  symptoms,  fresh  air,  prevention,  infection, 
nature  of  the  disease,  etc.,  going  into  such  detail  as  is  neces- 
sary to  give  the  patient  a  general  knowledge  of  the  subject 
discussed,  so  that  he  may  co-operate  with  the  physician  and 
nurse  in  an  intelligent  manner.  Each  patient  is  provided  with 
a  book  in  which  he  keeps  a  record  of  the  weight,  temperature, 
and  pulse,  after  instruction  by  the  nurse ;  the  food  consumed 
daily,  both  as  to  character  and  amount;  the  number  of  hours 
spent  in  the  open  air;  the  daily  amount  and  character  of  the 
work  or  exercise ;  any  unusual  symptoms  or  change  in  pre- 
vious symptoms ;  and  the  treatment  carried  out.  In  this  way  a 
complete  record  is  kept  of  the  daily  lives  of  the  patients,  which 
is  much  more  accurate  and  reliable  than  that  given  from  mem- 
ory. These  records  are  gone  over  carefully  each  week,  and 
any  mistakes  are  noted  and  used  as  texts  for  the  talks  given  to 
the  class.  The  patients  are  also  given  an  opportunity  to  ask 
questions  in  regard  to  tuberculosis,  the  entire  class  receiving 
the  benefit  of  the  answer. 

By  this  class  method  of  treatment  it  is  possible  to  develop 
the  intelligent  co-operation  and  esprit  de  corps,  which  could 
not  be  gained  in  any  other  way.  It  is  also  possible  in  this 
way  to  go  into  minute  detail  in  regard  to  the  purchasing, 
selection,  preservation,  and  preparation  of  food,  and  the 
nutrient  value  of  various  articles  of  diet,  which  is  impossible 
in  the  regular  dispensary  method.  The  patients  can  be  shown 
how  to  make  beds  properly  for  sleeping  in  the  open-air,  and 
how  to  make  their  own  window  tents,  home-made  refriger- 
ators and  fireless  cookers.  They  receive  an  education  such 
as  would  equal  that  obtained  in  the  best  sanatoria,  and,  in 
addition,  obtain  information  such  as  is  provided  by  very  few 
sanatoria.  The  mistakes  of  others  serve  as  warnings  to  all, 
and  the  improvement  of  every  patient  acts  as  a  stimulus  to  the 
others  to  do  likewise.    The  results  obtained  by  this  method  of 


436 


DISEASES    OF   THE   RESPIRATORY   SYSTEM. 


treatment  naturally  depend  upon  the  enthusiasm,  patience, 
tact,  and  resourcefulness  of  the  physician  and  nurse  in  charge, 
and  to  a  much  greater  extent  than  is  ordinarily  the  case. 
Some  care  is  necessary  in  the  selection  of  the  patients  who 
seem  adapted  to  this  method  of  treatment. 

Children  who  are  below  weight,  anemic,  subject  to  fre- 
quent colds,  and  who  present  evidence  of  infection  may  be 
treated  by  this  same  method,  only  modified  to  meet  the 
altered  conditions.  The  talks  should  be  simple,  and  only  such 
subjects  covered  as  fresh  air,  overexercise,  tea  and  coffee, 
excessive   candy-eating,    cleanliness,    and    care    of   the    teeth, 


Fig.  19. — Appliances  used  for  instructing  patients  in  the  use 
of  home-made  refrigerators- and  fireless  cookers.  The  charts 
shown  on  wall  are  used  to  illustrate  the  relative  value  of  various 
foodstuffs.     (Henry  Phipps  Institute,  University  of  Pennsylvania.) 

nails,  and  hair.  The  children  may  also  be  encouraged  by 
prizes  for  improveinent  in  health  or  general  cleanliness,  if 
deemed  advisable.  The  weight,  "temperature,  and  pulse  are 
taken  only  every  two  weeks,  and  no  daily  record  is  kept. 
After  the  talk  has  been  given,  the  children  are  seen  one  at  a 
time,  and  allowed  to  return  home  at  once,  unless  there  is 
special  reason  for  an  examination,  such  as  excessive  tempera- 
ture, loss  of  weight,  or  increase  of  symptoms.  While  a  few 
of  the  children  may  show  signs  of  tuberculous  disease,  either 
of  the  glands,  bones,  or  lungs,  the  majority  of  those  suitable 
for  this  method  of  treatment  belong  to  that  large  group  in 


PULMONARY  TUBERCULOSIS. 


437 


which  one  suspects  the  possibility  of  beginning  disease  in  an 
infected  child,  who  betrays  no  definite  evidence  of  tuber- 
culous disease.- 

The  proper  treatment  of  dispensary  patients  is  practically 
impossible  without  a  certain  amount  of  home  visitation  by 
experienced,  tactful,  well^trained  nurses.  By  ''well-trained 
nurses"  is  meant  nurses  who  have  had,  in  addition  to  their 
hospital  training',  instruction  in  public  health  and  social 
service  work.  Hospital  training  is  necessary  for  their  proper 
appreciation  of  illness  and  all  that  it  implies,  and  an  experi- 
ence in  the  treatment  of  disease.     In  no  other  way  can  a  dis- 


Fig.    20. — Cross    section    of    home-made  .refrigerator.       (Henry 
Phipps  Institute,  University  of  Pennsylvania.) 

pensary  worker  gain  a  foothold  in  a  family  as  adviser  and 
friend  save  through  actual  assistance  at  the  bedside  of  the 
sick.  The  public  health  work  is  also  necessary  to  secure  a 
broader  view  of  the  question  of  disease,  the  methods  by  which 
it  may  be  studied,  and  its  effect  upon  the  general  public  wel- 
fare, together  with  the  factors  which  are  concerned  in  its 
cause  and  dissemination.  A  social  service  experience  is  of  the 
utmost  value,  inasmuch  as  it  helps  to  solve  the  economic  fac- 
tors which  play  such  an  important  part  in  many  cases,  sug- 
gests plans  for  correcting  the  evils  discovered,  and  provides 
ways  and  means  for  bringing  to  bear  in  the  individual  case 
the   resources   of  the   charitable   and   philanthropic   organiza- 


438  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

tions,  or  to  assemble  the  family  resources,  as  the  case  may 
be.  The  dispensary  should  not  supply  the  patients  with  any- 
thing obtainable  by  any  other  means,  so  that  it  may  not  be 
viewed  as  a  charit}'.  A  dispensary  should  be  looked  upon  by 
the  patients  as  a  place  where  the}-  may  go  freely,  when  unable 
to  pay  a  physician,  to  receive  advice  and  medical  attention. 
This  feeling  can  be  secured  only  by  careful  attention,  and  not 
by  the  distribution  of  food  and  money.  AVhen  the  dispensary 
doles  out  charit}'  it  is  attended  only  by  such  patients  as  are 
unscrupulous  or  devoid  of  self-respect,  or  by  self-respecting 
patients  when  the  disease  has  become  advanced,  their  every 
cent  having  been  spent  before  they  would  resort  to  charity. 
While  ever}'  means  should  be  employed  to  prevent  the  dispen- 
sary being  abused  by  those  able  to  pay,  it  is  a  great  mistake, 
in  dealing  with  a  disease  like  tuberculosis,  to  draw  the  line  too 
closely,  as  even  after  the  disease  has  become  quiescent  and  a 
certain  amount  of  work  is  permissible,  the  patient  should,  if 
possible,  possess  a  certain  amount  of  money  in  reserve,  so 
that  he  may  not  be  forced  to  work  beyond  his  strength. 

One  of  the  greatest  difficulties  in  the  proper  management 
of  the  invalid  poor  is  their  tendency  to  drift,  or  to  be  sent  from 
one  dispensar}'  to  another.  This  may  be  overcome  by  having 
connected  with  the  tuberculosis  dispensary  such  additional 
clinics  as  frequently  may  be  required.  Thus  every  well 
equipped  tuberculosis  dispensar}^  should  have  certain  adjunct 
clinics  for  the  treatment  of  nose  and  throat  conditions,  dis- 
eases of  infancy,  and,  if  possible,  a  dental  clinic.  A  g^meco- 
logical  dispensary  equipped  to  handle  prenatal  cases  is  of 
inestimable  value.  While  an  .i--ray  laborator}',  especially 
equipped  for  the  work,  may  at  times  be  of  use,  the  dii^cul- 
ties  attending  the  securing-  of  an  operator  of  sufficient  experi- 
ence make  it  appear  wiser  in  the  majority  of  cases  to  have  the 
work  done  in  a  convenient  ,r-ray  laboratory  attached  to  a 
general  hospital,  if  one  be  nearb}'. 

There  are  several  plans  which  have  been  suggested  to 
meet  the  needs  of  the  tuberculous  patients  in  whom  the  dis- 
ease has  become  arrested,  or  who  are  unable  to  attend  a 
sanatorium.  For  one  who  is  able  to  work,  the  night  dispen- 
ssivy  will  prove  a  deeply  appreciated  help.  The  night-camp 
situated  just  outside  the  city,  or  on  the  roof  of  some  large 


PULMONARY    TUBEkCULOSIS. 


439 


Figs.  21  and  22.— Open-air  school.  Conducted  by  the  Henry  Phipps  In- 
stitute, Univeirsity  of  Pennsylvania,  on  the  roof  of  the  College  Settlement, 
Philadelphia,    showing    the   necessary    equipment   for    cold    weather. 


440  DISEASES    OF    THE   RESPIR.-\TORY    SYSTEM. 

building,  may  also  be  of  value  to  this  same  class  of  cases,  by 
providing  a  place  where  they  may  sleep  out  of  doors  under  the 
best  conditions  they  can  obtain.  For  the  patients  who  must 
be  at  rest  for  a  large  portion  of  the  time  the  day-camp  may 
be  employed,  preferably  within  easy  reach  of  the  patient's 
home.  The  river  piers,  roofs,  and  parks  have  been  used  for 
these  day-camps. 

There  is  .a  large  group  of  children  who  show  evidence  of 
infection  without  any  definite  signs  of  actual  tuberculous  dis- 
ease ;  they  are  underweight,  poorly  nourished,  pale,  and  usu- 
ally subject  to  coughs  and  colds.  In  other  words,  their  ap- 
pearance makes  one  suspect  beginning  disease  without  any 
demonstrable  evidence  upon  which  to  base  such  a  suspicion. 
If  these  children  are  to  avoid  the  later  development  of  disease 
and  become  useful  members  of  the  community,  it  is  necessary 
that  their  general  health  and  nutrition  be  brought  up  to  the 
highest  point  possible.  It  is  equally  necessary  that  they 
receive  an  .education  and  such  training  and  care  as  their 
home  life  permits.  To  care  for  this  group  of  cases  open-air 
schools  have  been  developed,  and  in  the  larger  cities  are  being 
provided  in  an  ever-increasing  number.  The  pupils  spend 
their  entire  school-hours  in  the  open  air,  either  on  the  roof, 
or  in  a  room  from  which  the  window  sashes  have  been  re- 
moved. To  meet  the  altered  conditions,  it  is  necessan,-  that 
they  be  provided  with  proper  clothing  and  extra  covering. 
A  warm  cap,  mittens,  sweater,  coat,  bloomers,  and  sitting-out 
bag  are  indispensable  in  ver}-  cold  weather  (Fig.  21).  The 
success  attending  open-air  schools,  not  only  in  the  freedom 
from  disease  and  in  the  improvement  in  general  health,  but 
also  in  quickened  mentality,  must  be  seen  to  be  appreciated. 
A  fairly  extensive  experience  with  open-air  schools  makes  one 
w^onder  why  all  schools  are  not  conducted  upon  this  same 
plan.  The  general  improvement  to  be  manifested  in  health 
and  mentality,  if  all  children  were  educated  in  the  open  air, 
would  more  than  repay  the  slight  inconvenience  which  this 
method  might  entail — to  say  nothing  of  the  saving  in  coal. 

Children  suffering  from  active  tuberculous  disease  should 
not  be  placed  in  open-air  schools.  The}'-  are  just  as  much  in 
need  of  rest  as  adults  who  have  an  active  process.  For  this 
reason  the  word  tuberculosis  should  not  be  associated  with 


PULMONARY    TUBERCULOSIS.  441 

open-air  schools,  for  it  tends  to  mislead  and  give  a  false  im- 
pression to  the  children  and  their  families,  and  to  the  public. 

One  of  the  most  important  functions,  therefore,  of  the  dis- 
pensary is  the  gathering  in  of  all  cases  suggesting  the  pos- 
sibility of  tuberculosis,  rejecting-  the  non-tuberculous  or  un- 
suitable, determining  the  presence  or  absence  of  activity  in 
the  tuberculous,  and  outlining  the  appropriate  course  of  treat- 
ment as  seems  best  suited  to  each  case.  Those  with  active 
disease  are  sent  to  a  sanatorium  or  hospital,  or  placed  under 
the  proper  conditions  at  home,  and  those  with  evidence  of 
infection  without  active  disease  merely  instructed  in  the 
proper  way  of  living,  and  cautioned  against  the  conditions 
which  might  tend  to  stir  up  activity.  The  cases  in  which 
there  is  doubt  as  to  whether  the  pulmonary  process  is  active 
or  not  should  also  be  instructed  in  the  proper  mode  of  living, 
and  should  be  told  to  report  at  frequent  intervals,  so  that  they 
may  be  kept  under  observation.  There  can  be  no  question 
that  there  is  considerable  room  for  education  in  regard  to  the 
difference  in  the  requirements,  depending  upon  whether  the 
case  is  merely  infected  or  actually  has  tuberculous  disease, 
not  only  among  social  workers,  nurses,  and  dispensary 
workers,  but  among  physicians  as  well.  Probably  one  of  the 
most  important  functions  of  an  efficient  tuberculosis  dispen- 
sary is  the  opportunity  it  offers  for  the  education  of  medical 
students,  nurses,  and  social  workers.  The  ignorance  of  this 
most  important  disease  which  still  exists  is  appalling,  in  spite 
of  the  widespread  campaigns  of  education,  for  this  instruc- 
tion has  been  directed  mainly  toward  the  laity,  with  the  pro- 
fessional classes  almost  ignored. 

TREATMENT    OF    SPECIAL    SYMPTOMS. 

Gastro-intestinal  Disturbances.  In  a  very  large  proportion  of 
tuberculosis  cases  the  symptoms  which  call  for  active  medicinal 
treatment  are  referable  tO'  some  disturbances  of  the  stomach  or 
intestines,  and  in  many  instances  these  symptoms  are  the  first 
indication  of  the  disease,  and  not  infrequently  precede  for  a  con- 
siderable time  any  symptom  suggesting  disease  of  the  lungs.  It 
is  unfortunate  that  in  a  condition  where  recovery  depends  to  such 
a  marked  degree  upon  the  nutrition  of  the  patient  that  these 
defects  of  digestion  should  sO'  frequently  develop. 


442  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

The  most  common  symptoms  are  those  dependent  upon  the 
lack  of  gastric  motility,  and  diminished  secretion,  so  com- 
monly present  in  tuberculosis,  even  in  its  early  stages. 

It  is  impossible  to  consider  in  a  general  article  all  of  the 
numerous  gastric  symptoms  which  may  arise  in  the  course  of  this 
disease,  but  there  are  a  few  which  occur  so  frequently,  or  are  so 
serious  in  their  nature,  that  they  merit  being  considered  in  some 
detail. 

Loss  of  Appetite.  In  the  early  stages  of  the  infection  loss  of 
appetite  responds  quickly  to  the  outdoor  treatment,  and  when  this 
symptom  appears,  the  first  step  for  its  correction  should  consist 
in  an  investigation  of  the  amount  of  fresh  air  the  patient  is  obtain- 
ing. In  the  event  of  it  being  clearly  shown  that  there  is  no  defi- 
ciency of  fresh  air,  it  is  necessary  to  determine  whether  the  evac- 
uation of  the  intestinal  tract  is  regular  and  sufficient.  It  is  only 
in  the  more  advanced  cases  that  it  will  be  found  necessary  to 
resort  to  the  use  of  nux  vomica,  gentian,  and  similar  drugs  before 
meals  in  order  to  stimulate  the  desire  for  food.  It  must  be 
remembered  that  when  the  patient  is  taking  milk  and  eggs  at 
fairly  frequent  intervals  it  may  be  that  the  time  between  feedings 
is  too  brief,  on  account  of  the  lack  of  gastric  motility,  and  it  may 
be  found  necessar}^  to  give  the  feedings  at  longer  intervals.  Hot 
water  in  the  mornings,  with  or  without  tlie  addition  of  sodium 
phosphate  (not  the  effervescing),  frequently  has  a  very  beneficial 
eft'ect.  lodin,  has  been  recommended  in  the  treatment  of  this 
symptom  in  the  form  of  the  tincture  of  iodin  (U.  S.  P.)  admin- 
istered in  milk  or  water  either  one-half  hour  before  or  during  the 
meal,  the  dose  being]  a  few  drops  three  times  a  day,  gradually 
increased  to  10  drops  (0.6  mil),  or  even  more.  Creosote  in  small 
doses,  when  properly  administered,  will\  in  many  instances/  prove 
invaluable  in  stimulating  the  appetite  (see  p.  448). 

Vomiting.  While  thisi  symptom  is  not  uncommonly  observed 
in  advanced  cases,  it  may  also  be  seen  occasionally  early  in  the 
disease.  Patients  suffering  from  severe  cough,  or  when  expec- 
torating large  quantities  of  tenacious  mucus,  very  frequently  have 
attacks  of  vomiting  after  the  coughing  spells ;  and  tliis  also  is  very 
prone  to  occur  immediately  after  the  ingestion  of  food.  In  such 
cases  it  is  obviously  the  cough  and  expectoration  which  require 
medication,  and  not  the  stomach,  although  special  care  must 
be  employed  in  the  selection  of  the  expectorants  to  be  used. 


PULMONARY    TUBERCULOSIS.  443 

A  very  common  cause  of  gastric  distress,  nausea,  and  vomiting 
is  the  formation  in  the  ^sitomach  of  large,  firm  clots  of  casein 
immediately  after  the  swallowing  of  milk,  under  which  circum- 
stances such  measures  should  be  employed  as  will  serve  to  break 
up  the  clots,  with  the  formation  of  finely  divided  particles  of 
casein,  rather  than  the  retention  of  large  firm  masses.  For  this 
purpose  it  may  occasionally  be  advisable  to^  allow  the  patient  to 
take  a  small  quantity  of  crackers  or  toast  with  the  milk,  but  what- 
ever is  taken  should  be  well  chewed  and  mixed  with  saliva  before 
swallowing,  and  never  soaked  in  the  milk.  Various  other  meas- 
ures that  may  be  tried  are:  Moderate  doses  of  sodium  bicarbo- 
nate or  milk  of  magnesia  before  each  feeding ;  lime  water  in  gen- 
erous doses  with  the  milk;  sodium  citrate,  two  grains  (0.13  Gm) 
to  the  ounce  (32  mils)  of  milk ;  dilution  of  the  milk  with  1  part 
of  A^ichy  to  2  of  milk;  or  possibly  some  of  the  commercial  infant 
foods  may  be  employed. 

When  vomiting^  of  thisi  type  oiccurs,  it  is  advisable  to  investi- 
gate carefully  the  diet,  to  determine  whether  too  much  food  is 
being  taken,  or  whether  the  intervals  between  the  feedings  are  too 
short.  It  may  be  found  that  thei  patient  is  drinking  the  milk  too 
rapidly,  and  it  may  be  necessary  to  instruct  the  patient  to  drink 
the  milk  slowly,  allowing  a  short  pause  between  mouth fuls.  Care- 
fully instructing  the  patient  in  regard  to  the  quantity,  time  of 
taking,  and  proper  method  of  drinking  milk,  will  very  frequently 
avoid  the  necessity  of  administering  medicine  or  modifying  the 
milk. 

Another  type  of  vomiting  occurs  about  one  hour  after  eating, 
and  is  usually  preceded  by  considerable  distress,  nausea,  and  eruc- 
tations O'f  gas.  This  type  isi  also'  more  commonly  seen  in  advanced 
cases,  but  occasionally  may  be  found  fairly  early  in  the  course  of 
the  disease.  This  type  of  emesis  requires  the  most  careful  treat- 
ment, and  at  times  it  may  even  be  found  necessary  tO'  discontinue 
all  food  by  the  mouth,  and  tO'  resort  to  rectal  feeding  for  a  short 
period. 

One  of  the  best  methods  of  handling  such  cases  is  to  reduce 
the  quantity  of  food  to  the  minimum  amount  possible.  No  solid 
food  should  be  taken,  and  the  milk,  only  in  small  quantities,  pre- 
ferably peptonized,  may  be  given  at  intervals  of  two  and  one-half 
hours.  It  is  usually  possible  after  a  few  days  of  such  feeding 
cautiously  to  increase  the  amount  of  milk,  and  then  gradually  tO' 


444  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

add  other  articles  of  diet.  Certain  of  these  cases  respond  very 
well  to  a  decrease  in  the  amount  of  fats,  a  few  days  upon  skimmed 
milk  and  the  white  of  eggs  sufficing  to  remedy  the  digestive  dis- 
turbance, 

While  the  above  suggestions  are  made  in  regard  to  vomiting, 
they  apply  equally  well  to  some  of  the  digestive  disturbances 
which  may  occur  without  vomiting.  A  not  infrequent  cause  of 
digestive  disturbance  is  the  swallowing  of  the  sputum,  which  the 
patient  may  do  unconsciousl}^,  and  it  is  a  good  plan  always  to> 
caution  the  patient  to  guard  against  its  occurrence.  There  is 
nothing  peculiar  about  the  gastric  symptoms  incident  tO'  pul- 
monary^ tuberculosis,  for  they  have  the  same  significance,  and  call 
for  the  same  methods  of  treatment,  as  when  encountered  in  other- 
wise healthy  individuals.  A  word  of  caution  is  not  out  of  place 
in  regard  to  the  use  of  the  stomach-tube.  In  an  early  case,  in 
^vhich  the  swallowing  of  the  tube  is  not  accompanied  by  any 
marked  disturbance,  such  as  violent  gagging  and  retching,  there 
can  be  no  possible  objection  to  its  use.  In  an  advanced  case,  sub- 
ject to  hemoptysis,  or  in  an  early  case  in  which  the  posterior 
pharynx  is  very  irritable,  and  in  which  the  passage  of  the  tube 
causes  considerable  gagging,  it  should  never  be  employed  unless 
absolutely  necessary,  and  then  only  with  the  greatest  care. 

There  are  very  few  casesi  that  will  be  able  to  take  sufficient 
nourishment,  especially  when  on  complete  rest,  without  being 
markedly  benefited  at  some  time  during  their  course  of  treatment 
by  the  occasional  administration  of  pepsin,  dilute  hydrochloric 
acid,  nux  vomica,  sodium  bicarbonate,  charcoal,  or  creosote, 
according  to  the  indications. 

Constipation.  When  taking  milk  and  eggs  it  is  extremely 
important  that  the  patient  secures  a  prompt  evacuation  of  the 
unabsorbed  residue,  as  otherwise  gastric  and  intestinal  disturb- 
ances and  evidences  of  general  autointoxication  will  quickly  mani- 
fest themselves.  A  very  common  belief  among  the  laity  is  that 
milk  is  constipating,  some  refusing  to  take  it  on  that  account  alone. 
While  some  do  suffer  at  first  from  this  distressing  symptom,  it 
can  frequently  be  overcome  by  increasing  the  amount  of  milk 
taken.  If  this  method  fails  to  bring  about  the  desired  result,  the 
usual  methods  of  correcting  constipation  may  be  instituted,  such 
as  massage,  a  generous  diet  of  coarse  grains  and  fruit,  at  the  mid- 
day meal,  with  vegetables,  especially  those  of  a  type  which  supply 


PULMONARY   TUBERCULOSIS.  445 

considerable  fibrous  residue  and  provide  sufficient  bulk  to-  stimu- 
late peristalsis.  If  it  is  necessary  to  resort  to  drugs,  heavy  min- 
eral oil  is  by  far  the  most  satisfactory,  although  it  may  be  neces- 
sary to  use  cascara  sagrada  in  some  instances.  Phenolphthalein 
in  doses  of  3  to  5  grains  (0.19  to  0.32  Gm.)  will  occasionally  be 
found  useful.  The  occasional  administration  of  a  saline  purge, 
preferably  magnesium  sulphate,  is  almO'St  essential  in  patients  in 
whom  the  feeding  is  being  forced,  especially  when  they  are  on 
absolute  res!t.  The  occasional  use  of  calomel,  always  being  fol- 
lowed by  an  active  saline  purge,  seems  tO'  be  of  considerable  bene- 
fit in  some  instances. 

Diarrhea  is  a  isymptom  which  occasionally  develops  in-patients 
on  a  milk-and-egg  diet,  or  even  at  times  when  one  is  taking  three 
regular  meals  a  day.  In  acute  attacksi,  thorough  evacuation  of 
the  bowel  with  Epsom  salts  or  castor  oil,  with  food  totally  sus- 
pended for  from  six  to  twelve  hours,  and  then  cautiously  resumed 
in  the  form  of  a  bland,  non-irritating  diet,  will  usually  prove  suf- 
ficient. If,  on  the  other  hand,  it  should  persist,  the  general  diges- 
tive function  of  the  patient  should  be  carefully  studied,  and  an 
effort  made  to  discover  just  what  is  responsible  for  the  loose 
bowels.  It  may  mean  incomplete  digestion,  with  the  appearance 
in  the  stools  of  large  quantities  of  partly  digested  food ;  occasion- 
ally the  fats  may  be  responsible,  or  possibly  it  may  result  from  an 
unsuspected  constipation  with  resulting  irritation  and  fermen- 
tation. A  daily  movement  oi  the  bowels  does  not  exclude  the 
possibility  of  constipation,  since  loose  material  may  tunnel 
through  a  tenacious  mural  mass  of  fecal  matter.  One  should 
always  investigate  the  purity  of  the  milk,  as  in  many  instances 
contaminated  milk  is  responsible,  but  in  some  cases  it  will  be 
found  that  the  only  cause  for  its  appearance  is  the  milk  itself, 
even  when  perfectly  clean  and  pure.  One  should  discontinue 
milk  as  a  food  only  after  being  thoroughly  convinced  that  it  is 
responsible  for  the  symptoms,  by  a  careful  study  of  the  gastric 
digestion  and  the  correction  of  any  defects  found.  A  trial  of  the 
various  intestinal  ferments  or  of  the  agents  used  to  stimulate 
their  secretion  should  be  made,  and  a  careful  investigation  of  the 
source  of  the  milk  supply,  with,  if  necessary,  a  bacterial  count  of 
the  milk,  is  to  be  undertaken ;  and  the  fats  eliminated  for  a  short 
period,  substituting  skimmed  for  the  whole-milk.  If  the  milk  is 
not   found   responsible  for  the  diarrhea,   and   if   this   symptom 


446  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

should  continue  even  after  it  has  been  discontinued,  decrease  of 
the  starchy  and  fatty  food  for  a  short  period,  with  a  relative  in- 
crease of  the  proteids,  and  the  administration  of  bismuth  sub- 
nitrate,  bismuth  subgallate,  or  one  of  the  tannin  preparations,  fre- 
quently corrects  the  condition.  Where  considerable  fermentation 
accompanies  the  diarrhea,  active  ciiltures  of  Bulgarian  bacilli, 
small  quantities  of  heavy  mineral  oil,  charcoal,  and  creosote  will 
.be  found  of  considerable  value,  and  in  some  cases  an  abdominal 
binder  may  relieve  the  tendency  to  frequent   watery  movements. 

In  advanced  cases  it  has,  been  shown  by  post-mortem  exami- 
nations that  tuberculous  ulceration  of  the  intestines  is  of  very 
frequent  occurrence,  and  in  the  presence  of  persistent  diarrhea 
this  factor  should  be  carefully  considered  as  a  possible  source  of 
this  distressing  and  grave  symptom. 

In  treating  any  and  all  of  the  disturbances  of  digestion  one 
m^ust  constantly  remember  that  the  disorder  may  not  be  due  to 
any  organic  condition,  but  may  be  essentially  of  nervous  origin. 
Many  of  the  disturbances  will  frequently  respond  to  moderate 
doses  of  bromids,  which  plan  of  treatment  should  be  given  a 
trial  before  resorting  to  more  radical  measures  in  any  case  in 
which  there  is  a  probability  of  the  disorder  being  of  this  type. 

Cough.  The  cough  accompanying  tuberculosis  may  be  due  to 
a  variety  of  causes,  and  in  the  treatment  of  this  symptom  it  is 
necessary  to  study  the  patient  with  the  object  of  determining  its 
sources  before  resorting  toi  medication.  Laryngeal  implication  or 
inflammation,  abnormalities  of  the  upper  air-passages,  digestive 
disturbance,  pleural  effusion,  enlarged  bronchial  glands,  or  pul- 
monaiy  congestion  may  be  responsible  for  the  cough.  As  a  mat- 
ter of  fact,  in  the  properly  managed  case  of  pulmonary  tubercu- 
losis, cough  is  not  a  very  prominent  or  distressing  symptom,  not- 
withstanding the  view  to  the  contrary  so  commonly  held.  A 
patient  whoi  is  under  the  proper  general  conditions  usually  coughs 
only  when  there  is  a  collection  of  mucus  to  be  expectorated,  and 
the  cough  necessary  to  raise  the  mucus  is  usually  so  slight  asi  to 
be  hardly  noticeable.  The  patient  with  pulmonary  tuberculosis  is 
usually  given  entirely  too  many  drugs,  and  most  of  these  are 
directed  toward  checking  the  cough.  So  long  as  there  is  a  tend- 
ency tow^ard  activity  of  the  process  in  the  lungs,  there  is  bound 
to  be  a  certain  amount  of  expectoration,  which  is  really  one  of 
nature's  methods  of  elimination.     It  must  be  evident,  therefore, 


PULMONARY    TUBERCULOSIS.  447 

that  the  expectoration  of  a  moderate  amount  of  material  is  neces- 
sary for  the  welfare  of  the  patient,  as  evidenced  by  the  rise  of 
temperature  and  other  evidences  of  toxemia  so  frequently  appear- 
ing upon  the  cessation  of  expectoration.,  or  a  sudden  decrease  of 
its  amount.  It  is  only  when  the  expectoration  is  accompanied  by 
severe  coughing  efforts  that  any  medication  is  required,  or  when 
there  is  a  very  hard,  dry,  unproductive  cough.  Many  patients 
who  complain  of  considerable  unproductive  cough  may  be  taught 
to  suppress  it.  It  is  astonishing  how  much  can  be  done  with  some 
patients  along  this  line,  when  the  physician's  instructions  are 
faithfully  followed.  In  a  properly  conducted  sanatorium,  whose 
inmates  have  irnstilled  into  them  constantly  the  importance  of  not 
giving  way  to  the  desire  to  coiigh,  even  when  many  of  them  are 
advanced  cases,  it  is  remarkable  how  little  coughing  one  hears, 
except  possibly  in  the  early  morning  hours.  It  is  important  to 
impress  upon  the  patient  the  fact  that  one  cough  leads  to  another, 
and  that  the  effort  to  suppress  a  cough  assures  them  of  a  consider- 
able period  withoul^  this  symptom.  They  may  be  encouraged  by 
being  informed  that  a  few  days  of  effort  are  all  that  is  necessary, 
as  after  that  time  the  supp^ression  becomes  automatic.  The  morn- 
ing cough  is  necessary  toi  remove  the  mucus  which  has  collected 
during  the  night,  and  does  not  require  any  special  treatment, 
unless  the  mucus  is  of  such  a  tenacious  character  that  toO'  violent 
an  effort  is  required  to  dislodge  it. 

Tuberculous  patients,  like  every  one  else,  at  times  may  develop 
a  cough  which  will  require  treatment,  but  many  of  them  will  be 
saved  a  great  deal  O'f  discomfort,  if  not  actual  harm,  if  the  attend- 
ing physician  would  only  bear  in  mind  that  cough  is  a  symptom 
in  pulmonary  tuberculosis  wdiich  does  not  usually  require  medical 
treatment.  The  acute  or  chronic  bronchitis  in  a  tuberculous 
patient  requires  the  same  treatment,  according  tO'  indications,  as 
other  individuals,  as  described  in  the  chapters  dealing  with  these 
conditions.    (See  Acute  and  Chronic  Bronchitis,  p.  326,  et  seq.) 

The  question  of  deciding  whether  a  patient  may  be  permitted 
to  smoke  must  be  decided  in  the  individual  case.  The  factors 
influencing  one  in  deciding  that  smoking  must  be  discontinued  are 
the  presence  of  pharyngeal  or  laryngeal  inflammation,  failure  to 
gain  in  weight,  gastro-intestinal  disturbances,  or  persistent  unpro- 
ductive cough.  Many  patients  who  have  smoked  for  years  derive 
an  immense  amount  of  comfort  from  itobacco,  without  the  least 


448  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

apparent  harm  in  many  instances.  Excessive  smoking  should  be 
absolutely  forbidden.  The  period  immediately  after  eating  seems 
to  be  the  one  in  which  the  craving  for  tobacco  is  greatest,  and  the 
time  during  which  it  is  most  advisable  to  permit  its  use.  Inhala- 
tion of  the  smoke  should  be  discouraged,  and  for  this  reason  the 
use  of  cigarettes  should  be  forbidden,  as  one  finds  it  easier 
to  refrain!  from  inhaling  the  smoke  from  a  pipe  or  a  mild  cigar. 
The  use  of  the  pipe  is  probably  best  in  these  cases,  as  it  permits 
of  a  wide  range  of  tobacco  from  which  to  select,  and  no  tobacco 
or  its  products  enters  the  mouth,  provided  the  stem  of  the  pipe  is 
frequently  cleansed.  When  the  habit  is  not  of  man}''  years  stand- 
ing, or  when  the  patient  does  not  progress  favorably,  it  is  prob- 
ably safer  to  break  off  smoking  entirely  than  to  attempt  to  limit 
the  amount. 

Creosote  is  one  of  the  drugs  which  has  been  credited  with 
special  and  peculiar  virtue  in  the  treatment  of  pulmonar}^  tubercu- 
losis, and  it  might  be  of  interest  toi  say  a  few  words  in  regard  to 
the  indications  for  its  use,  the  method  of  administration,  and 
other  details. 

At  the  time  creosote  was  first  recommended,  the  only  form  in 
which  tuberculosis  of  the  lungs  was  recognized  was  what  is  termed 
consumption — in  other  words,  only  in  the  advanced  stage  or 
actively  spreading  form.  Those  of  the  hectic  type,  or  what  is  now 
considered  as  those  with  mixed  infection,  were  the  cases  in  w^hich 
this  drug  was  considered  as  being  especially  indicated.  It  is  in 
just  'these  cases  that  creosote  gives  the  best  results,  w^hen  the  ex- 
pectoration is  profuse  and  purulent,  and  when  there  is  evidence  of 
a  breaking-down  process  in  a  consolidated  or  densely  infiltrated 
pulmonary  focus.  It  is  not  indicated  in  the  average  early  or  mod- 
erately advanced  patient,  in  whom  these  conditions  are  not  usually 
present.  There  is  a  common  belief  that  creosote  tends  to  disturb 
digestion,  and  should  not  be  employed  where  there  is  any  sign  of 
gastric  disturbance.  On  the  contrary,  when  properly  given,  it  may 
be  continued  for  long  periods  of  time,  not  only  without  interfer- 
ing with  digestion,  but  in  many  instances  improving  the  appetite, 
and  correcting  any  tendency  toward  fermentation  in  the  gastro- 
intestinal tract.  The  method  of  administration  which  seems  to 
have  given  the  best  results  in  the  hands  of  the  writer  is  in  moder- 
ately small  doses,  one  drop  (0.07  mil)  gradually  increased  to  5 
(0.35  mil)  or  even  10  drops  (0.64  mil),  stirred  in  a  large  cup 


PULMONARY    TUBERCULOSIS.  449 

of  very  hot  water,  and  not  Ijcing  drunk  until  the  small  droplets 
can  no  longer  be  seen  floating  upon  the  surface.  The  best  time 
to  give  it  is  one  hour  before  meals,  but  as  this  is  very  difficult  to 
carry  out  before  breakfast,  it  is  usually  more  convenient  to  ad- 
minister it  only  twice  daily,  preceding  the  mid-day  and  evening 
feedings.  While  many  advocate  the  emplo3'ment  of  larger  doses, 
the  amount  stated  usually  will  be  found  sufficient,  and  better  re- 
sults generally  are  obtained  if  the  drug  is  administered  for  a  few 
weeks,  then  discontinued  for  a  week,  and  then  renewed,  these 
short  periods  without  the  drug  being  of  considerable  help,  when  it 
is  desirable  to  continue  the  use  of  the  creosote  over  an  extended 
period  of  time. 

Opium  derivatives,  to  control  the  cough,  are  employed  entirely 
too  frequently  in  pulmonary  tuberculosis.  They  are  of  consider- 
able value  in  exceptional  cases,  or  in  certain  complications,  but 
should  never  be  used  as  a  routine  measure  in  early  or  in  moder- 
ately advanced  cases.  When  one  is  dealing  with  an  advanced 
case,  on  the  contrary,  it  is  criminal  to  withhold  the  comfort  and 
relief  which  may  be  obtained  from  heroin,  codein,  or  even  mor- 
phin.  The  unfavorable  after-eft'ects  are  more  than  counter-bal- 
anced in  these  instances  by  the  prolonged  periods  of  relative  com- 
fort, and  there  is  no  danger  of  forming  a  habit  which  might  prove 
as  serious  as  the  original  disease,  as  in  the  case  of  those  in  whom 
there  is  a  possibility  of  recovery  from  the  tuberculous  process. 

When  the  mucus  is  very  tenacious,  and  accompanied  by  hard 
coughing  spells,  there  is  no  drug  which  can  be  compared  with 
ammonium  chlorid  in  5-grain  (0.32  Gm.)  doses  four  to  six  times 
a  day,  preferably  after  meals.  This  drug  may  be  continued  for 
months,  if  so  desired,  without  interfering  in  any  way  with  diges- 
tion, provided  that  it  is  given  in  an  aqueous  solution,  or  with  one 
of  the  bitter  elixirs,  such  as  the  elixir  of  calisaya.  It  should 
never  be  given  in  the  various  popular  synips,  as  the  patient  will 
soon  be  forced  to  discontinue  its  use  on  account  of  gastric  dis- 
turbance. These  cough-syrups  are  undoubtedly  responsible  for 
the  prevalent  belief  that  ammonium  chlorid  is  a  drug  which 
should  not  be  continued,  for  any  length  of  time  on  account  of  its 
deleterious  action  upon  the  stomach. 

Pain.  There  are  ver}^  few  cases  of  pulmonary  tuberculosis 
that  go  through  the  course  of  their  disease  without  some  pain  in 
the  chest  at  some  time  or  other.     In  considering  the  pains  occur- 


450  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

ring  in  this  disease,  no  further  reference  will  be  made  here  to  the 
pains  due  to  a  frank  pleurisy  or  to  gastric  disturbance,  as  they 
will  be  considered  under  the  chapters  dealing  with  those  subjects. 

A  very  common  type  of  pain  is  the  one  referred  to  the  region 
of  the  chest  between  the  scapulae,  or  in  the  area  corresponding  to 
the  angle  of  either  scapula.  This  pain  usually  arises  when  patients 
have  permitted  themselves  to  become  exhausted,  either  mentally 
or  physical^,  and  is  of  a  dull,  boring,  neuralgic  character.  The 
remedy  for  this  tj^pe  of  pain  consists  of  absolute  or  approximately 
absolute  rest,  and  the  building  up  of  the  patient's  general  strength. 
Local  remedies  occasionally  will  give  relief,  especially  counter- 
irritation  with  tincture  of  iodin  or  mustard,  or  in  some  cases  the 
salicylates  may  give  temporary  relief,  although  there  are  numer- 
ous objections  to  their  being  continued  for  any  considerable  time. 

Pain  in  the  shoulder  is  not  at  all  uncommon,  and  is  usually 
extremely  difficult  to  relieve;  the  severe,  sharp  pains  which  usu- 
ally occur  in  the  shoulder  on  the  affected  side,  but  may  affect  the 
opposite  shoulder,  are  usually  worse  at  night.  Dry  heat  is  the 
measure  which  usually  gives  the  greatest  amount  of  relief,  com- 
bined with  rest  of  the  joint  and  gentle  massage  or  counter-irrita- 
tion with  iodine,  or  small  blisters,  frequently  repeated.  The  pains 
may  occur  in  other  joints  in  the  body,  such  as  hips,  knees,  elbows, 
or  wrists,  and  when  not  due  to  definite  disease  of  the  joints,  may 
be  treated  along  the  same  lines  as  suggested  for  the  management 
of  the  pains  in  the  shoulders.  It  is  advisable  in  these  cases  to 
search  for  hidden  foci  of  infection,  including  a  careful  examina- 
tion of  the  teeth. 

A  dull,  aching  pain,  or  occasional  sharp,  shooting  pains,  occur 
fairly  frequently  over  the  upper  anterior  chest.  It  has  been 
thought  that  these  are  produced  by  pleural  inflammation  or  adhe- 
sions, which  usually  accompany  an  apical  process.  While  the 
pleurae  may  be  responsible  in  some  cases,  this  cannot  always  be 
true,  as  the  pains  not  infrequently  occur  upon  the  unaffected  side. 
It  would  seem  that  certain  of  these  pains  must  be  muscular,  or 
possibly  neuralgic,  on  account  of  their  location  and  general 
character.  The  same  local  and  general  measures  may  be  employed 
in  this  type  of  pain  as  that  previously  described.  Very  often  dry 
cups,  or  small  blisters,  frequently  repeated,  prove  of  benefit.  As 
the  drugs  which  may  be  used  for  the  relief  of  these  pains  are 
certainly  not  beneficial,  if  not  actually  harmful,  to  the  general  con- 


PULMONARY   TUBERCULOSIS.  451 

di'tion  of  the  patient,  it  is  desirable,  whenever  possible,  to  employ 
local  measures  for  their  relief,  rather  thani  internal  medication. 

It  is  a  very  good  practice  to  warn  patients  that  these  pains  are 
likely  to  occur,  that  they  do  not  signify  inflammation  of  the  lung, 
or  extension  of  the  disease,  and  to  allow  them  to  panit  the  chest 
with  tincture  of  iodin  when  they  occur.  Another  convenient 
method  of  securing  counter-irritation  is  to  have  the  patient  soak 
a  few  rough  towels  in  a  strong  salt  solution,  which  are  then 
allowed  to  dry,  and  may  then  be  employed  for  rubbing  the  chest 
when  the  pains  occur.  While  heat  will  at  times  relieve  the  pain, 
most  patients  seem  better  off  if  they  can  secure  the  desired  relief 
by  the  other  local  measuresi  above  enumerated. 

Rubbing  the  chest  with  oil  seems  to  be  followed  by  more  relief 
in  some  cases  than  can  be  obtained  by  any  other  measure,  espe- 
cially when  a  certain  proportion  of  oil  of  gaultheria  is  added. 
When  it  is  desired  to  administer  iodin,  some  of  the  various 
preparations  may  be  combined  with  the  oil.  A  favorite  formula 
for  rubbing  with  oil,  highly  recommended  by  some  physicians,  not 
only  for  the  relief  of  pain,  but  for  its  apparent  beneficial  effect 
upon  the  general  condition,  is  the  following: 

Oil  of  gaultheria  f3ij    (8  mils). 

Europhen  (28%  iodine)    3ij   (8  Cms.). 

Olive    oil    (or    cottonseed    oil) 

q.  s ad  f §vj   (64  mils) . 

Sig.    One  teaspoon ful  (4  mils)  rubbed  into  the  chest  night  and  morning. 

For  the  same  purpose  the  following  mixture  is  applied  in  the 
same  manner : 

Iodin  crystals    gr.  xxx  (2  Cms.). 

Lanolin    Hss  (32  Cms.) . 

Olive  or  cotton-seed  oiL.q.s.  ad  5.vj    (192  mils). 
Ether  q.  s. 

Hemoptysis.  It  has  been  said  that  60  per  cent,  of  tuberculous 
cases  present  this  symptom  at  some  time  durin'g  the  course  of 
the  disease.  The  degree  of  the  hemoptysis  may  var}-  from 
blood-streaked  sputum  to  the  sudden  massive  hemorrhages 
which  cause  death  almost  instantly.  There  must  be  many 
causes  for  the  raising  of  the  blood,  the  slight  bleedings  being 
probably  due  to  congestion  or  the  rupture  of  small  vessels, 
while  the  raising  of  small  clots,  so  frequently  seen  in  cavity 


452  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

cases,  is  almost  certainly  due  to  oozing  from  small  vessels. 
In  others  this  SA'^mptom  is  accompanied  by  signs  which  seem 
to  indicate  the  presence  of  a  pneumonic  process,  possibly  as 
a  result  of  the  rapid  extension  of  the  tuberculous:  disease. 
There  are  certain  cases  in  which  the  hemorrhages  do  not 
occur  until  the  patient  is  apparently  well  on  the  road  to 
recovery. 

From  this  exceedingly  brief  description  can  be  readily 
seen  the  difficulties  which  attend  any  effort  to  lay  down  a 
fixed  rule  or  outline  a  single  method  of  treating  this  symptom. 
In  treating  any  case  of  pulmonary  hemorrhage  an  effort 
should  be  made  first  to  discover  the  exact  cause  of  the  bleed- 
ing. AVhile  theoretically  this  is  extremely  desirable,  in  prac- 
tice it  presents  many  difficulties,  the  greatest  of  which  is  the 
danger  attending  moving  the  patient  to  the  extent  necessary 
for  a  thorough  examination,  and  of  the  lungs  particularly, 
with  reference  to  percussion,  and  to  the  deep-breathing  so 
necessary  for  a  satisfactory  auscultatory  examination.  This 
means  that  the  source  or  nature  of  the  bleeding  must  be  de- 
termined largely  by  the  temperature,  symptoms,  character  of 
expectorated  blood,  and  previous  knowledge  of  the  case,  sup- 
plemented by  what  one  may  elicit  by  auscultation  of  the  chest 
without  change  of  posture  or  deep-breathing  on  the  part  of 
the  patient.  While  this  materially  limits  the  field  of  investi- 
gation, one  frequently  may  derive  sufficient  information  upon 
which  to  base  a  very  accurate  conception  of  the  location  and 
nature  of  the  process  responsible  for  the  bleeding.  Many  of 
the  hemorrhages  met  with  are  not  of  a  serious  nature,  being 
checked  by  very  little  or  no  treatment;  but  it  seems  hardly 
wise  to  proceed  upon  such  an  assumption,  in  A'iew  of  the  fact 
that  some  of  them  are  so  extremely  serious.  As  our  present 
means  of  differentiating  the  hemoptysis  due  to  the  various 
causes  is  not  as  perfect  as  one  might  wish,  it  would  seem 
advisable  to  treat  all  of  them,  no  matter  how  slight  they 
might  be,  as  a  serious  symptom. 

A  very  important  factor,  if  not  the  most  important,  in 
treating  any  case  of  hemoptysis,  is  for  the  physician  to  re- 
assure the  patient.  The  mental  excitement  and  worry  result- 
ing from  the  expectorating  of  blood  is  usualh^  extreme,  and 
undoubtedly   is   frequently   responsible   for   the    continuation 


PULMONARY    TUBERCULOSIS.  453 

of  the  bleeding,  so  that  the  most  essential  element  in  the 
treatment  of  the  condition  is  rest,  not  only  absolute  physical 
rest,  but  mental  as  well.  The  patient  should  be  put  to  bed, 
and  not  allowed  to  leave  it  for  any  reason  so  long  as  the 
bleeding  continues,  and  in  fact  should  be  kept  as  near  abso- 
lute quiet  as  is  possible.  The  posture  which  the  patient 
should  assume  is  the  one  in  which  he  is  most  comfortable  and 
the  one  least  likely  to  excite  a  cough.  When  the  bleeding 
comes  from  a  ruptured  vessel,  the  most  essential  point  in  the 
treatment  is  the  lowering  of  the  blood-pressure,  and  absolute 
mental  and  physical  rest  are  two  extremely  valuable  means 
we  possess  for  bringing  about  this  reduction.  The  common 
practice  of  inducing  quiet  by  giving  repeated  doses  of  mor- 
phin  in  all  cases  of  hemoptysis  is  not  to  be  recommended,  for 
this  drug  possesses  too  many  deleterious  effects.  The  excit- 
ability and  restlessness  may  usually  be  effectually  controlled 
by  moderate  doses  of  bromids,  but  in  some  cases  it  will  be 
found  absolutely  necessary  to  administer  morphin  or  iTeroin, 
although  never  for  any  length  of  time,  and  only  in  amount 
sufficient  to  quiet  the  patient.  In  employing  morphin  one 
must  be  extremely  careful  not  to  give  it  in  such  doses  as  will 
produce  heavy  sleep  or  absolutely  prevent  cough.  A  certain 
amount  of  cough  is  necessary  to  remove  the  blood  accumu- 
lating in  the  bronchi,  in  spite  of  any  ill  effects  which  may 
possibly  result  from  the  cough  by  disturbing  the  clotting  at 
the  bleeding-point.  For  further  reducing  the  blood-pressure 
there  is  no  drug  which  is  as  satisfactory  as  the  nitrites,  given 
in  the  form  of  nitroglycerin,  amyl  nitrite,  or  sodium  nitrite. 
A  tablet  of  %oo  of  a  grain  (0.00064  Gm.)  of  nitroglycerin,  dis- 
solved on  the  tongue,  usually  has  the  desired  effect,  and  may 
be  repeated  sufficiently  often  to  maintain  the  reduction  of  the 
blood-pressure.  As  it  has  been  shown  that  tablets  of  nitro- 
glycerin, are  occasionally  inert,  the  spirit  of  glonoin  (1  per  cent, 
alcoholic  solution  of  nitroglycerin)  may  be  employed  in  doses 
of  1  to  2  minims  (0.0648  to  0.1296  Gm.)  every  hour.  Some 
care  must  be  exercised  in  employing  the  spirit  of  glonoin,  as, 
if  the  preparation  is  stale,  it  may  be  stronger  than  it  should 
be,  as  a  result  of  concentration  from  evaporation  of  the 
alcohol.  Owing  to  this  tendency,  the  drug  should  never  be 
prescribed  in  full  strength,  but  should  be  diluted  with  water. 


454  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

1  or  2  minims  (0.062  or  0.123  mil)  to  the  dram  (4  mils)  as 
desired.  The  nitrogl}xerin  should  be  administered  at  frequent 
intervals,  as  its  effect  is  very  fleeting,  the  dose  desired  being 
repeated  ever}"  hour  until  the  pulse  or  the  patient's  symptoms 
indicate  that  the  desired  eft"ect  or  physiologic  limit  has  been 
reached,  when  the  inter^'als  between  the  doses  may  be 
increased.  AMien  a  very  quick  eft'ect  is  desired,  especially  in 
an  emergency,  the  inhalations  of  amyl  nitrite  are '  to  be  pre- 
ferred. Veratrum  viride  has  also  been  recommended  for  this 
purpose,  as  it  is  claimed  that  lowered  pressure  is  maintained 
for  a  longer  period  of  time  than  is  the  case  with  the  nitrites, 
in  which  the  effect  is  ver^^  evanescent.  A  very  common  prac- 
tice  is  to  apply  an  ice-bag  to  the  chest,  over  the  bleeding-point 
when  it  can  be  located.  As  the  ice-bag  frequenth^  aft'ords  a 
sense  of  reassurance  to  the  patient,  and  helps  to  maintain  the 
patient  absolutely  quiet,  it  may  be  continued  if  so  desired, 
but  preferably  it  should  be  placed  over  the  heart,  and  not 
over  ,the  suspected  bleeding-point  in  the  lungs.  The  main- 
taining of  a  low  pressure  is  ver}^  important,  and  for  this 
reason  all  cases  of  hemorrhage  should  be  carefully  watched. 
The  drugs  which  have  been  used  as  a  means  of  reducing  the 
blood-tension  should  never  be  suddenly  withdrawn,  but 
should  be  given  at  progressively  longer  intervals  after  the 
bleeding  has  ceased,  and  then  discontinued  at  the  end  of 
several  days.  Emetin  has  also  been  used  Avith  considerable 
success  in  the  treatment  of  hemoptysis,  numerous  very  favor- 
able reports  having  been  published  in  the  past  few  years  upon 
the  use  of  this  drug.  Emetin  may  be  given,  preferably  liypo- 
dermically.  in  34 -grain  (0.0486  Gm.)  doses  three  or  four  times 
a  day,  using  either  the  hypodermic  tablets  or  ampoules.  The 
drugs  which  have  been  recommended  at  one  time  or  another 
for  the  treatment  of  this  condition  are  without  number,  but 
the  majority  of  cases  will  respond  better  to  the  plan  of  treat- 
ment above  outlined  than  to  au}^  other,  as  the  use  of  numer- 
ous diff'erent  drugs  in  this  emergency  frequentl}-  is  respon- 
sible for  unfavorable  results. 

In  order  to  secure)  the  formation  of  a  clot  at  the  bleeding- 
point,  which  is  the  object  of  all  treatment  of  hemorrhage, 
there  are  two  factors  necessary :  the  tension  of  the  blood  must 
be  reduced,  so  that  the  clot  may  not  be  forced  away  from 


PULMONARY    TUBERCULOSIS.  455 

the  opening-,  and  the  blood  must  possess  the  ability  to  coag- 
ulate. Unfortunately  the  methods  at  our  command  for  in- 
creasing the  coagulability  of  the  blood  are  either  unreliable 
or  do  not  act' quickly  enough  to  be  of  use  in  an  emergency. 
For  patients  who  are  subject  to  hemorrhage,  the  administra- 
tion of  calcium  lactate  in  full  doses  over  a  rather  prolonged 
period  of  time  may  prove  of  benefit.  Ordinary  table  salt  has 
been  for  many  years  a  very  popular  home  remedy  for  hemop- 
tysis and  may  be  employed  in  5-  to  15-  grain  doses  (0.324  to 
0.972  Gm.).  It  has  been  shown  that  sodium  chlorid  in 
creases  the  coagulability  of  the  blood  very  quickly,  but  the 
effect  is  not  lasting.  Ten  to  15  mils  (2  fo  42  min.  to  4  fo'  4 
min.)  of  a  10  per  cent,  solution  of  sodium  chlorid,  injected 
intravenously,  also  has  been  recommended,  the  solution  being 
heated  to  body  temperature  before  use.  Care  must  be  taken 
to  prevent  any  of  the  solution  leaking  into  the  subcutaneous 
tissues,  as  it  may  cause  extreme  pain.  Sodium  bromid  has 
very  much  the  same  effect  as  sodium  chlorid,  and  is  to  be 
preferred  for  administration  by  the  mouth,  especially  in 
nervous  subjects. 

The  tying-off  of  the  blood  in  the  extremities  by  means  of 
turniquets  has  also  been  recommended  for  increasing  the 
coagulability  of  the  blood.  The  constriction  of  the  arms  or 
hips  must  be  performed  carefully,  to  avoid  injury  to  the  tis- 
sues, and  should  not  be  maintained  longer  than  one-half  to 
one  hour,  the  bandages  being  removed  very  slowly  at  the  end 
of  this  time.  It  is  to  be  hoped  that  the  more  recent  studies 
upon  the  coagulability  of  the  blood  will  result  in  providing 
some  rapid  method  for  determining  the  factor  at  fault  in  any 
case  with  decreased  coagulability,  and  will  suggest  some 
agent  for  quickly  and  satisfactorily  supplying  the  deficiency. 
The  rather  empiric  method  for  increasing  the  coagulability  by 
injecting  horse  serum  has  been  recommended,  naturally  with 
greatly  varying  results.  Care  must  be  exercised  when  horse 
serum  is  given  repeatedly,  to  make  sure  that  the  patient  has 
not  become  sensitized,  and  warning  is  to  be  given  of  the 
potential  dangers,  akin  to  those  which  may  attend  the  admin- 
istration of  diphtheria  antitoxin. 

When  the  site  of  the  bleeding-  can  be  absolutely  deter- 
mined,   artificial    pneumothorax    has    been    strongly    recom- 


456  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

mended  as  a  means  of  controlling  the  hemorrhages.  This 
procedure  has  the  disadvantage,  first,  of  being  applicable  only 
to  a  limited  number  of  cases,  and,  second,  the  disturbance  of 
the  patient  necessary  to  carry  out  the  procedure  is  not  without 
a  certain  risk.  Where  the  hemorrhages  are  severe  and  pro- 
longed, and  the  bleeding-point  can  be  located  without  any 
question,  it  offers  a  means  of  absolutely  controlling  pulmo- 
nary hemorrhage. 

Pyrexia.  There  is  nothing  peculiar  about  the  temperature 
course  in  pulmonary  tuberculosis,  unless  one  can  consider  its 
protean  character  as  distinctive.  The  temperature  in  an  un- 
complicated case  is  practicalh'  always  subnormal  in  the  morn- 
ing, although  occasionally  the  inverse  type  is  met  with,  in 
which  the  subnormal  pliase  occurs  in  the  afternoon.  When 
the  temperature  continues  elevated,  it  usually  indicates  the 
presence  of  some  complication.  A  rise  of  temperature  always 
demands  rest  in  bed  and  careful  observation,  regardless  of  its 
cause,  and  it  frequently  indicates  an  increased  activity  in  the 
pulmonary  process.  Slight  temporary  rises  ma}-  result  from 
over-exertion  or  fatigue,  menstruation,  over-excitement,  gas- 
tro-intestinal  disturbances,  or  the  presence  of  an  acute  infec- 
tion, such  as  cor\'za,  tonsillitis,  or  bronchitis.  The  more 
serious  conditions  in  which  the  first  indication  of  their  pres- 
ence may  be  a  rise  of  temperature  are :  pleurisy,  hemoptysis, 
meningitis,  pneumonia,  and  an  acute  general  miliary  tuber- 
culosis. 

Fever  is  not  infrequent  in  pulmonar}-  tuberculosis,  and 
may  occur  at  any  stage  of  the  disease,  but  is  naturally  more 
frequent,  excessive,  and  resistant  to  treatment  in  the  advanced 
cases.  In  the  earlier  stages,  when  due  to  an  exacerbation  of 
the  pulmonary^  process,  it  will  usuall}^  respond  quickly  to  gen- 
eral hygienic  measures,  the  most  important  of  which  is  abso- 
lute rest,  as  described  in  dealing  with  the  subjects  of 
Rest  and  Exercise  (see  p.  412).  Occasionally  cases  will  be  en- 
countered in  which  these  general  measures  appear  to  be  in- 
sufficient to  overcome  the  toxemia  responsible  for  this  symp- 
tom, and  under  such  circumstances  it  will  be  found  necessary 
to  resort  to  other  measures  in  order  to  make  the  patient  com- 
fortable. Bathing  with  water  is  b}^  far  the  most  satisfactory 
means  of  securing  a  reduction  of  the  temperature.     This  may 


PULMONARY    TUBERCULOSIS.  457 

be  carried  out  with  tepid,  cool,  or  c\'en  iced  water,  depending 
upon  the  amount  of  fever  and  the  rapidity  with  which  the 
temperature  falls  after  the  bath.  Some  patients  with  even  a 
fairly  high  fever  respond  quickly  to  the  tepid  bath,  but  in 
others  iced  water  is  required  before  the  temperature  tends  to 
decline  and  a  certain  amount  of  comfort  is  obtained.  The 
addition  of  alcohol  to  the  water  is  very  refreshing  and  agree- 
able to  most  patients.  Occasionally  a  hot  foot-bath  will 
serve  the  same  purpose  as  the  cool  bath,  especially  if  mustard 
be  added  to  the  hot  water. 

In  applying  the  cool  sponge  it  will  usually  be  found  suffi- 
cient to  bathe  the  extremities,  although  there  is  no  objection 
to  bathing  the  entire  body,  provided  that  care  is  taken  to  see 
that  the  patient  is  thoroughly  dried  afterward,  without  too 
brisk  a  rubbing  with  the  towel. 

Drugs  for  the  reduction  of  temperature  should  never  be 
resorted  to,  except  in  extreme  cases.  The  class  of  drugs  which 
will  help  to  lower  the  fever  has  a  distinctly  unfavorable  efifect 
upon  the  patient,  especially  if  persisted  in  for  a  considerable 
time.  Occasionally,  when  a  sudden  rise  of  temperature  does 
not  respond  to  the  measures  suggested,  and  is  accompanied  by 
general  severe  discomfort  and  distress,  it  may  be  permissible 
to  employ  drugs  for  this  purpose.  The  most  satisfactory  is 
phenacetin  in  doses  of  2  or  3  grains  (0.13  or  0.19  Gm.),  re- 
peated every  two  hours  for  three  or  four  doses,  in  which 
quantity  it  may  be  considered  safe  and  at  the  same  time 
effective.  Aspirin  also  may  be  given  for  this  purpose  in  5- 
grain  (0.32  Gm.)  doses  three  or  four  times  a  day.  While 
quinin  is  without  the  depressing  effect  of  some  of  the  other 
antipyretics,  it  is  seldom  that  it  exerts  any  appreciable  effect, 
but  it  may  be  tried  when  other  methods  have  failed. 

Night-sweats.  A  symptom  which  may  prove  very  disturbing 
to  the  patient  is  the  occurrence  of  profuse  sweating  at  night. 
This  is  not  only  annoying-  to  the  patient,  but  usually  leaves 
them  with  a  sense  of  exhaustion,  and,  what  is  more  serious, 
while  in  the  wet  state  exposes  them  to  chilling,  which  may 
have  a  very  unfavorable  effect  upon  their  general  condition. 
This  symptom  is  of  relatively  infrequent  occurrence  in  early 
cases,  being  more  common  in  patients  with  moderate  dissem- 
ination of  an  acute,  actively  spreading  type,  and  in  those  with 


45S  DISEASES    OF   THE   RESPIR-\TORY   SYSTEM. 

extensive  consolidation.  As  a  rule,  night-sweats  occlif  ifl 
those  patients  who  present  that  group  of  symptoms  commonly 
believed  to  indicate  the  presence  of  mixed  infection.  Con- 
trary to  the  belief  commonly  held,  the  sense  of  depression 
following  the  sweats  is  due  to  the  conditions  responsible  for 
this  symptom,  and  not  to  the  sweating  itself. 

It  will  be  found  in  nearly  ever}-  instance  that  the  mere 
placing  of  the  patient  under  improved  hygienic  conditions, 
with  sufficient  fresh  air,  and  a  regulation  of  the  diet,  entirely 
checks  the  occurrence  of  this  symptom.  A\'henever  it  appears, 
a  careful  investigation  should  be  made  of  the  patient's  mode 
of  living,  inquiring  particularly  into  the  amount  of  rest,  time 
spent  in  the  open  air,  method  of  securing  fresh  air,  clothing, 
bathing,  diet,  occurrence  of  constipation,  and  any  other  detail 
which  suggests  itself  in  .causal  relationship.  It  will  usually 
be  found  that  there  is  some  hygienic  error  responsible  for  the 
night-sweats,  the  correction  of  which  will  prevent  their  fur- 
ther occurrence  without  an)-  special  treatment. 

Cases  are  occasionally  met  with  which  require  more  active 
and  specific  treatment,  especially  those  with  a  lesion  of  the 
caseating,  actively  spreading  type.  Here  it  will  be  necessary 
to  tr}-  to  improve  the  general  tone  of  the  patient  by  cool 
baths;  these,  when  administered  in  the  evening  just  before 
going  to  sleep,  seem  to  be  especially  valuable.  The  addition 
of  vinegar  or  alcohol  to  the  cool  water  with  which  the  patient 
is  sponged  occasionally  increases  its  efficiency.  A  cool  sponge 
in  the  morning,  or  a  cold  chest-bath,  will  often  prove  of  benefit 
in  these  cases.  It  has  also  been  advised  to  administer  a  small 
quantity  of  brandy  or  whiskey  on  retiring,  or  a  short  time  be- 
fore the  sweats  usually  occur. 

A  glass  of  hot  milk,  or  even  a  small  quantity  of  solid  food, 
such  as  toast  or  roll,  may  be  employed  instead  of  the  alcoholic 
beverage.  AMien  the  measures  suggested  fail  to  check  the  night- 
sweats,  a  trial  may  be  made  of  various  drugs,  among  which 
atropin  sulphate,  in  doses  of  %oo  to  ^4-5  oi  a  grain  (0.00064 
to  0.00086  Gm.)  on  retiring,  is  by  far  the  most  satisfactory. 
Other  drugs  which  have  been  recommended  are :  camphoric 
acid,  calcium  salts,  and  agaricin,  which  ma}-  be  given  a  trial 
if  other  methods  of  treatment  should  prove  unavailing,  al- 
though it  is  only  reasonable  to  expect  very  little  from  the 


PULMONARY   TUBERCULOSIS.  459 

Use  of  drugs  in  those  cases  in  which  the  general  hygienic 
measures  prove  useless.  The  ideal  treatment  for  this  condi- 
tion naturally  involves  the  elimination  or  correction  of  the 
toxins  responsible  for  the  sweating,  rather  than  the  mere 
relief  of  the  symptoms. 

Anemia.  Anemia  of  the  chlorotic  type,  of  varying  severity, 
is  frequently  present  in  pulmonary  tuberculosis,  and,  while  not 
infrequently  present  in  early  cases^  is  more  common  in  the 
advanced. 

This  chloroanemia  is  of  the  type  which  one  would  natur- 
ally expect  should  respond  to  iron  medication  most  readily, 
and  yet  in  many  instances  the  results  are  far  from  satisfac- 
tory. There  are  various  forms  in  which  the  iron  may  be  ad- 
ministered, such  as  the  tincture  of  the  chlorid  of  iron,  Blaud's 
pills  (carbonate),  peptomanganate  of  iron,  syrup  of  the 
iodid  of  iron,  and  ovoferrin.  The  hypodermic  administration 
of  the  citrate  of  iron  is  strongly  recommended  by  some 
writers,  and  while  this  mode  of  administration  possesses  cer- 
tain disadvantages  the  possibility  of  gastric  derangement  and 
constipation  are  eliminated.  The  following  formulas  have 
been  recommended : 

L      Iron  citrate   0.1         Gm.   (ly.  gr.). 

2.  Iron  citrate   0.05       Gm.   (^  gr.). 

Strychnin  sulphate  0.0005  Gm.   (^/'i20  gr.). 

Sodium  arsenate  0.001     Gm.   C/'oo  gr.). 

3.  Iron  citrate   0.05       Gm.   (^gr.). 

Metarsinate  of  sodium 0.01       Gm.   (%  gr.). 

Strychnin  sulphate 0.001     Gm.   (^/^o  gr.). 

These  combinations  are  strongly  recommended  by  Peters  and 
Bullock,  who  state  that  the  hemoglobin  content  of  the  blood 
may  be  brought  up  to  normal  by  20  daily  injections. 

In  view  of  the  unfavorable  effect  of  arsenic  in  so  many 
cases,  and  the  questionable  value  which  it  possesses  in  the 
secondary  anemia  of  pulmonary  tuberculosis,  it  would  seem  to 
be  much  wiser  to  omit  the  use  of  this  drug,  unless  great  care 
can  be  exercised  in  its  administration,  and  the  patient  kept 
under  constant  observation. 

The  best  results  in  the  treatment  of  this  symptom  in  the 
average  case  are  obtained  by  a  generous  supply  of  fresh  air 
and  nutritious  food. 


460  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

COMPLICATIONS. 

Tuberculous  Pleurisy.  The  treatment  of  this  condition  has 
been  covered  in  a  separate  section  (see  Pleurisy,  p.  502),  and 
yet  it  would  seem  advisable  to  call  attention  to  several  points 
in  the  treatment  of  special  significance  when  this  complication 
occurs  in  tuberculosis. 

In  the  first  place,  the  pleural  effusion  which  occurs  without 
any  evident  etiologic  factor  should  be  looked  upon  in  the  same 
light  as  one  would  view  hemoptysis  under  the  same  conditions, 
namely,  as  in  all  probability  being  tuberculous  in  origin.  The 
tuberculous  pleurisy  may  precede  distinct  clinical  evidence  of  pul- 
monary tuberculosis  by  many  years,  and  should  always  be  treated 
as  any  other  case  of  tuberculosis  regardless  of  the  absence  of  pul- 
monary signs.  Every  case  in  which  no  evident  cause  for  the 
appearance  of  an  effusion  can  be  discovered  should  be  treated  just 
as  one  would  treat  an  incipient  case  oi  pulmonary  tuberculosis. 
The  patient  should  be  brought  up  to  the  highest  degree  of  nutri- 
tion, and  not  allowed  to  return  to  an  ordinary  mode  of  living  until 
one  has  become  convinced  of  their  full  ability  to  resume  such  a 
life.  They  should  be  constantly  kept  under  observation,  and  a 
careful  examination  of  the  lungs  made  at  fairly  frequent  inter- 
vals. It  is  best  to  insist  upon  a  rational  mode  O'f  life,  with  fresh 
air  in  abundance  whenever  possible,  even  after  the  patient  has 
resumed  his  or  her  regular  occupation.  If  after  the  pleurisy  has 
cleared  up,  the  patient  is  underweight,  tires  easily,  or  shows  a 
tendency  to  an  elevation  of  temperature  or  pulse,  a  period  of 
treatment  under  careful  observation  such  as  one  would  obtain  in 
a  sanatorium  is  absolutely  necessary  to  prevent  the  development 
of  pulmonary  tuberculosis  at  a  later  date. 

Treatment.  There  is  one  point  in  regard  to  the  treatment 
of  pleural  effusion  in  subjects  of  pulmonary  tuberculosis  which 
cannot  be  too  frequently  repeated,  and  that  is  the  serious  re- 
sults which  may  follow  the  sudden  withdrawal  of  large  quan- 
tities of  serum.  Where  there  is  tuberculosis  of  the  lung,  one 
of  the  most  important  points  in  the  treatment  is  the  obtain- 
ing of  as  nearly  complete  functional  rest  of  the  lung  as  pos- 
sible. When  a  pleural  effusion  occurs  there  is  produced 
naturally  the  conditions  which  we  strive  to  obtain  by  arti- 
ficial pneumothorax  in  the  treatment  of  this  condition — the 
lung  is  put  at  absolute  rest.    The  sudden  withdrawal  of  the  fluid 


PULMONARY    TUBERCULOSIS.  461 

causes  abrupt  distension  of  the  lung,  with  not  infrequently  a  rapid 
extension  of  the  disease  as  a  result.  When  the  effusion  becomes 
so  massive  that  the  mere  bulk  of  the  serum  causes  distress  and 
severe  dyspnea,  a  small  amount  of  the  fluid,  sufficient  to^  relieve 
the  distressing  symptoms,  may  be.  slowly  withdrawn.  Whenever 
possible  it  is  advisable  to  have  the  effusion  absorbed,  as  this  seems 
to  exert  a  favorable  efTect  upon  the  general  condition  of  the 
patient,  although  the  exact  way  ini  which  this)  autoserotherapy  is 
exerted  has  not  been  definitely  determined.  It  has  been  recom- 
mended that  massive  effusions  be  completely  withdrawn,  air  or 
nitrogen  gas  being*  introduced  at  the  same  time,  the  gas  injected 
replacing  the  fluid.  In  this  way  compression  of  the  lung  is  main- 
tained, and  presumably  there  is  less  likelihood  of  the  effusion 
becoming  purulent.  This  replacement  O'f  fluid  by  gas  impresses 
one  as  an  unnecessary  interference,  subjecting  the  patient  to  the 
discomfort  of  frequent  injections  of  gas  which  could  be  avoided, 
and  at  the  same  time  producing  conditions  which  favor  the  reac- 
cumulation  of  the  fluid.  The  encouragement  of  a,  gradual  absorp- 
tion of  the  fluid  seems  much  more  desirable,  unless  the  process 
in  the  lung  distinctly  indicates  the  advisability  of  an  artificial 
pneumothorax,  regardless  of  the  pleural  effusion. 

The  favorable  effectsi  which  frequently  follow  the  absorption 
of  effusions  has  led  to  efforts  to  bring  about  similar  conditions 
artificially.  The  most  common  means  of  inducing  autosero- 
therapy is  by  the  use  of  large  blisters  (4"  by  4"  or  4"  by  6"), 
care  being  taken  to  avoid  breaking  the  skin  in  their  application. 
The  cantharides  blisters  are  applied  until  distinct  redness  of  the 
skin  develops,  the  time  required  varying  in  different  individuals 
from  one  to  three  hours,  when  the  plaster  is  removed  and  the 
formation  of  the  vesicle  assisted  by  means  of  hot,  moist  com- 
presses. After  the  blister  is  formed  a  carefully  applied  absorbent 
cotton  dressing  is  necessary  to  prevent  its  rupture,  and  to  allow 
the  serum  contents  to  be  absorbed. 

In  the  treatment  of  tuberculous  effusions  the  injection  into 
the  pleural  space  of  various  substances  has  been  recommended, 
with  the  object  of  curing  any  tuberculous  disease  of  the  pleura. 
Among  the  substances  suggested  are  iodoform  and  glycerin  (10 
to  20  mils  of  glycerin  containing  a  20  per  cent,  suspension  of  iodo- 
form), formalin  and  glycerin,  iodin  and  glycerin,  and  similar 
mixtures  and  combinations.    Care  must  be  used  to  avoid  injecting 


462  DISEASES    OF    THE    RESPIR-\TORY    SYSTEM. 

substances  which  permit  of  ready  absorptioiii  with  the  develop- 
ment of  general  toxic  effects.  The  advisabilit}'  of  injecting  anti- 
septic solutions  into  pleural  effusions  is  still  open  to  question,  fur- 
ther experience  with  this  method  of  treatment  being  necessary 
before  it  can  be  proved  to  be  without  danger,  and  to  possess  dis- 
tinct advantages  over  the  present  methods  of  treatment.  When 
the  effusion  becomes  purulent  it  must  be  treated  as  any  other 
form  of  empyema,  r^ardless  of  the  pulmonary  process,  but  so 
long  as  it  is  serous  it  may  be  left  in  the  pleural  space  indefinitely, 
the  danger  of  permanent  contraction  of  the  Imig  or  serious  dimi- 
nution of  expansion  being  so  remote  a  possibility  that  such  com- 
plications may  be  disregarded.  It  is  astonishing  to  find  how 
quickly  a  lung  which  has  been  compressed  for  a  considerable  time 
will  regain  its  normal  or  nearly  normal  expansion  when  the  com- 
pression is  removed,  provided  there  has  been  no  marked  inflam- 
matory- thickening  in  the  pleura  or  extensive  disease  in  the  lung. 

Tuberculous  Pneumothorax.  This  complication  may  occur 
in  patients  with  onh-  a  moderate  phthisical  infection,  but  it  is 
usuall)-  met  with  in  advanced  cases  with  cavity  formation,  the 
thin  walls  of  which  rupture  with  the  consequent  passage  of 
air  into  the  pleural  space.  As  cavities  usualh-  contain  infective 
material,  w^hich  also  gains  entrance  to  the  pleural  space  with 
the  air,  it  is  extremely  rare  to  find  a  pneumothorax  which  does 
not  become  a  pyo-pneumothorax  w-ithin  a  ver\^  short  space  of 
time.  In  treating  this  condition  this  fact  should  always  be 
borne  in  mind,  as  the  pneumothorax  alone  calls  for  treatment 
in  onl}'  a  ver\-  small  proportion  of  the  cases. 

Treatment.  The  occurrence  of  pneumothorax  usually  is  ac- 
companied by  pain  varying  in  degree  from  one  so  slight  as  to 
pass  almost  unnoticed  to  one_of  agonizing  severit5^  In  some 
cases,  however,  this  symptom  is  entireh'  absent,  and  the  pres- 
ence of  pneumothorax  may  be  entirely  unsuspected,  being  dis- 
covered onlv  during  the  course  of  a  routine  examination,  or  it 
mav  be  suspected  onh-  on  account  of  the  sudden  development 
of  dyspnea.  The  pain,  if  severe,  is  best  treated  by  morphin, 
and  it  mav  become  necessan.-  to  withdraw  some  of  the  air  from 
the  pleural  space  by  means  of  an  aspirating  apparatus,  if  the 
dvspnea  is  very  severe  or  if  pain  is  unrelieved  by  morphin. 
The  svmptoms  of  shock,  which  occasionally  accompany  the 
onset  of  pneumothorax,  may  call  for  fairly  active  stimulation. 


PULMONARY    TUBERCULOSIS.  463 

When  considering  the  advisabihty  of  removing  the  air  from 
the  pleural  space,  or  of  aspirating  a  serous  effusion  which  may 
develop  secondarily,  it  must  be  remembered  that  one  of  the  essen- 
tials of  a  cure  of  pnemnothorax  is  the  closure  of  the  pulmonar}^ 
opening.  The  closure  of  this  opening  is  more  likely  to  be  secured 
if  the  lung  remains  compressed,  whether  secured  by  the  -air  or 
by  fluid  in  the  pleural  space.  When  the  symptoms  demand  relief 
from  the  intrapleural  pressure  alone,  a  sufficient  quantity  of  the 
air  or  serous  fluid  should  be  removed  to  relieve  the  urgent  symp- 
toms, and  the  evacuation  never  carried  out  to  a  point  where 
re-expansion  of  the  compressed  lung  will  result. 

The  further  treatment  of  'the  case  will  have  to  be  determined 
by  the  extent  of  the  lesion,  the  generall  condition  of  the  patient, 
tlie  amount  of  pus  which  develops  in  the  pleural  space,  and  the 
severity  of  the  s3'mptoms.  Aspiration  of  the  pus  may  be  all  that 
the  condition  of  the  patient  will  warrant.  In  those  cases  where 
it  would  seem  advisable  to  prevent  the  re-expansion  of  the  lung, 
air  or  nitrogen  gas  may  be  introduced  simultaneously  with  the 
aspiration  of  the  pus.  By  this  method  the  removal  of  the  pus 
may  be  secured,  and  at  the  same  time  the  possibility  of  re-opening 
the  pulmonary  fistula  can  be  avoided.  As  the  outlook  for  recov- 
en,"  in  these  cases  is  ver}-  poor,  it  seems  as  if  the  best  hope  for  re- 
cover}' would  depend  upon  the  removal  of  the  pus  by  the  resection 
of  the  rib  and  the  insertion  of  a  drainage  tube,  when  the  patient's 
general  condition  permits  a  deliberate  operation  of  this  sort.  The 
selection  of  the  site  of  operation  and  the  method  of  drainage 
should  be  left  to  the  decision  of  the  surgeon. 

Mixed  Infections.  ^lan}-  cases  present  a  groilp  of  symp- 
toms, such  as  marked  elevation  of  temperature  of  a  hectic 
type,  night-sw^eats,  chills,  emaciation,  general  malaise,  diges- 
tive disturbances,  and  purulent  expectoration,  which  many 
clinicians  believe  are  indicative  of  the  presence  of  some  in- 
fective organism  other  than,  or  in  addition  to,  the  tubercle 
bacillus.  \Miile  in  some  instances  this  is  undoubtedly  true, 
more  recent  investigations  would  tend  to  show  that  this 
group  of  symptoms  may  be  produced  by  the  tubercle  bacil- 
lus alone.  In  advanced  pulmonan,-  tuberculosis  there  are 
usually  large  areas  in  the  lungs  lined  with  breaking  down 
caseous  material  or  fibroid  tissue,  which  offer  a  favorable 
nidus    for    bacterial    grow^th ;    and    while    these    secondary 


464  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

micro-org'anisms  ma}-  not  gain  access  to  the  blood-stream, 
there  is  no  reason  why  their  soluble  toxins  may  not  enter 
the  general  circulation,  and  be  responsible  for  the  symptoms 
characteristic  of  this  complication.  It  would  seem  wise  to 
■consider  the  foregoing  group  of  symptoms  as  indicative  of 
mixed  infection,  even  if  at  times  tuberculosis  alone  may  pos- 
sibly be  responsible  for  their  occurrence. 

Treatment.  These  cases  call  for  a  line  of  treatment  sug- 
gested in  the  sections  on  pyrexia  and  night-sweats,  remember- 
ing that  the  low  temperature  in  the  mornings  may  call  for 
treatment  with  warm  drinks,  hot  applications,  and  extra  cov- 
erings, just  as  the  febrile  period  of  the  day  calls  for  cold  ap- 
plications. These  cases  require  abundant  nourishment,  and 
under  no  conditions  should  the  amount  of  nutriment  be  dimin- 
ished merely  because  the  temperature  is  elevated. 

The  results  from  the  use  of  bacterial  vaccines  are  very 
striking  in  a  few  cases,  but  so  far  we  have  no  means  of  de- 
termining  which  are  the  cases  in  which  these  favorable  results 
may  be  expected.  In  the  majority  of  instances  no  effect  is 
obtained  from  vaccines,  and  in  a  few  cases  harm  seems  to 
result  from  their  use.  In  the  light  of  our  present  knowledge, 
if  the  usual  means  at  our  disposal  for  treating  this  condition 
prove  unavailing,  the  bacterial  vaccines  may  be  tried  cau- 
tiously, although  one  will  be  saved  considerable  disappoint- 
ment in  the  majority  of  cases  if  not  too  much  is  expected  from 
their  use.  Whenever  possible  it  is  advisable  to  employ  auto- 
genous vaccines,  although  occasionally  striking  results  may 
follow  the  use  of  stock  mixtures  of  the  bacteria.  The  method 
of  procedure  recommended  is  to  prepare  a  bacterin  containing 
all  of  the  micro-organisms  in  a  representative  sample  of  spu- 
tum, the  initial  dose  containing  25  million  bacteria,  which  is 
increased  by  20  per  cent,  every  three  to  five  days.  Care  should 
be  taken  to  avoid  producing  a  reaction,  the  best  guide  to  the 
proper  dosage  being  the  evidence  of  improvement  of  the 
symptoms.  Repeated  examinations  of  the  sputum  should  be 
made  and  the  bacterin  altered  to  correspond  with  the  changes 
in  the  bacterial  content  of  the  expectoration. 

Nephritis.  Many  cases  of  pulmonary  tuberculosis  in  which 
the  disease  is  of  long  standing  present  evidence  of  a  mild 
grade  of  chronic  parenchymatous  nephritis.    The  renal  disease 


PULMONARY   TUBERCULOSIS.  465 

may  even  be  the  actual  cause  of  death  in  a  small  proportion  of 
cases.  The  disease  of  the  kidneys  may  be  entirely  unsus- 
pected, and  discovered  only  in  the  routine  examination  of  the 
urine.  It  is  very  infrequent  to  find  the  general  symptoms  and 
signs  usually  associated  with  disease  of  the  kidneys,  with  the 
exception  of  anemia  and  gastro-intestinal  disturbances.  The 
diarrhea  occasionally  met  with  in  advanced  tuberculosis  may 
have  its  origin  in  the  decreased  elimination  by  the  kidneys. 

In  spite  of  the  relative  frequency  of  albumin  and  casts  in 
the  urine  in  advanced  pulmonary  tuberculosis,  prol^ably  due 
to  the  prolonged  elimination  of  toxins  of  various  origins,  the 
function  of  the  kidneys  seems  to  be  fairly  well  maintained  in 
a  large  proportion  of  the  cases,  if  one  may  judge  from  the  re- 
sults obtained  from  the  application  of  the  functional  renal 
tests. 

In  the  advanced  cases  which  show  large  quantities  of 
albumin  and  a  relatively  small  number  of  casts  in  the  urine, 
one  would  naturally  suspect  amyloid  changes  in  the  kidneys, 
which  are  frequently  accompanied  by  similar  changes  in  the 
spleen  and  liver. 

Treatment.  The  treatment  of  nephritis  in  the  tuberculous 
will  usually  call  for  the  exercise  of  judg'ment  in  restricting  the 
amount  of  protein,  and  at  the  same  time  maintaining  the  gen- 
eral nutrition  by  increasing  the  amount  of  fats  and  carbohy- 
drates. Many  of  the  cases  in  which  the  renal  process  is  not 
extensive,  and  the  kidneys  are  still  functionating  fairly  well, 
require  very  little  in  the  way  of  treatment  directed  toward  the 
kidneys  other  than  that  obtained  by  a  chang'e  of  diet.  Where 
the  general  health  appears  to  be  affected  by  the  renal  disease 
or  where  there  are  symptoms  definitely  due  to  the  renal  dis- 
ease, a  more  active  course  of  treatment  may  be  demanded. 
If  the  symptoms  of  nephritis  are  urgent,  it  may  be  necessary 
to  ignore  temporarily  the  tuberculous  process,  and  to  insti- 
tute treatment  regardless  of  its  presence.  Some  care  must 
be  used  in  employing  hot  baths  in  the  cases  in  which  they  may 
be  indicated,  when  any  marked  breaking  down  in  the  lungs 
exists.  Severe  hemoptysis  may  result  from  the  injudicious 
employment  of  hot  baths  or  packs  in  such  cases. 

Where  increased  elimination  by  the  intestines  is  desired, 
the  physician  in  charge  will  have  to  decide  in  the  individual 

30 


466  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

case  the  point  to  which  the  active  catharsis  may  be  carried 
without  seriously  endangeiing  the  patient  by  the  depletion 
and  the  attendant  loss  of  nutrition  and  strength  which  it  so 
frequently  produces.  Care  must  also  be  used  in  these  cases 
to  make  sure  that  the  open-air  treatment  is  not  accompanied 
by  chilling,  and  to  see  that  extra  precautions  are  used  to  make 
sure  that  the  patient  has  sufficient  bedding,  and  even  arti- 
ficial heat,  if  necessary,  when  in  the  open  air. 

Intestinal  Tuberculosis,  Approximately  70  per  cent,  of  all 
far  advanced  cases  of  pulmonary  tuberculosis  have  been  .found 
to  have  tuberculous  ulceration  of  the  intestines  when  examined 
post-mortem,  some  reports  showing  as  high  as  98  per  cent. 
This  gives  an  indication  of  the  frequency  of  this  complication 
in  the  advanced  or  terminal  stages  of  the  disease.  It  is  impos- 
sible to  state  how  frequently  it  may  be  present  in  the  early 
stages,  or  even  in  the  advanced  cases,  as  we  have  no  means  of 
determining  how  long  this  condition  may  have  existed  previous 
to  death.  Unfortunately  we  have  no  reliable  method  of  diag- 
nosing the  condition,  for  while  diarrhea,  pain,  tenderness,  and 
rigidity,  especially  in  the  right  iliac  fossa,  may  be  present  in 
tuberculous  ulceration  of  the  intestines,  it  may  occur  without 
any  of  the  above  symptoms,  or  the  symptoms  may  occur  with- 
out any  ulceration.  The  presence  of  tubercle  bacilli  is  value- 
less, if  there  is  tuberculosis  in  any  other  part  of  the  body,  and 
the  presence  of  occult  blood  in  the  stools  is  of  no  practical 
value.  Hemorrhages  from  the  bowels  have  been  considered  by 
some  writers  as  an  absolute  indication  of  tuberculous  ulcera- 
tion, but  the  diagnoses  in  the  cases  reported  were  merely  as- 
sumed, as  there  was  no  direct  examination  of  the  intestines  to 
support  such  an  opinion.  When  the  patient  has  been  progress- 
ing favorably,  or  has  remained  stationary  for  a  considerable 
period  of  time,  and  suddenly  either  ceases  to  improve  or  be- 
comes progressively  worse,  without  any  definite  patent  cause, 
and  without  any  apparent  change  in  the  pulmonary  process, 
the  possibility  of  tuberculous  ulceration  should  always  be 
suspected. 

Treatment.  The  treatment  of  this  condition  is  extremely 
unsatisfactory.  The  main  indication  is  the  removal  from  the 
diet  of  all  foods  which  leave  much  residue,  especially  those  in 
which  the  non-nutrient  portion  is  of  an  irritating  character. 


PULMONARY    TUBERCULOSIS.  467 

An  absolute  egg-and-milk  diet  probably  meets  the  indications 
better  than  any  other,  peptonizing-  of  the  milk  aiding  materially 
in  securing  the  desired  conditions.  A  bland  soothing  oil  seems 
to  give  considerable  aid  in  some  cases,  and  even  castor  oil 
combined  with  tincture  of  opium  is  of  considerable  value 
in  some  cases,  especially  when  diarrhea  accompanies  the 
condition. 

In  the  majority  of  cases  opiates  in  some  form  will  be 
found  an  essential  part  of  the  treatment.  The  intestinal  anti- 
septics are  of  very  little  value  in  the  treatment  of  these  ulcera- 
tive processes,  although  they  may  be  tried  in  the  patients  in 
which  there  are  certain  symptoms  indicative  of  intestinal 
tuberculosis,  but  in  whom  it  is  impossible  to  make  a  positive 
diagnosis.  Creosote  at  times  will  relieve  many  of  the  intes- 
tinal symptoms  associated  with  gaseous  fermentation.  Bis- 
muth subnitrate,  subgallate,  or  salicylate  will  help  consider- 
ably in  the  cases  associated  with  diarrhea,  the  subnitrate.  being 
the  most  satisfactory  salt. 

The  ulcerative  type  is  the  most  common  of  the  tuberculous 
processes  in  the  intestinal  tract,  but  occasionally  the  hyper- 
trophic form  is  encountered,  with  symptoms  usually  indicative 
of  stenosis  or  incomplete  obstruction  of  the  intestine.  In  this 
type  medicinal  treatment  is  valueless. 

Surgical  intervention  should  always  be  considered  in  any 
case  in  which  the  diagnosis  can  be  made  with  relative  cer- 
tainty, and  in  which  the  general  condition  of  the  patient  war- 
rants such  a  procedure,  or  where  the  condition  has  led  to 
repeated  hemorrhages  or  perforation.  The  operative  treat- 
ment is  naturally  more  clearly  indicated  in  those  cases  in  which 
the  intestinal  lesion  is  primary,  or  where  the  signs  indicate  a 
very  slight  or  quiescent  pulmonary  lesion. 

Tuberculous  Laryngitis.  In  a  work  of  this  kind  it  is  not 
the  place  for  a  detailed  description  of  the  various  methods  of 
treating"  tuberculous  laryngitis,  and  yet  it  might  not  be  amiss 
to  offer  a  few  suggestions  in  regard  to  the  treatment  in  general. 
The  majority  of  patients  with  tuberculous  laryngitis  onlv  ob- 
tain an  improvement  of  the  laryngeal  symptoms  when  the  gen- 
eral health  is  built  up — in  other  words,  the  laryngeal  condition 
is  best  treated  by  measures  directed  toward  the  general  welfare 
of  the  patient,  rather  than  by  local  measures  alone.    Most  cases 


468  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

do  better  without  much  treatment  of  the  larynx  itself,  unless 
there  are  very  definite  indications  for  such  intervention.  Ab- 
solute vocal  rest,  counter-irritation  in  the  form  of  small  blis- 
ters to  the  throat,  a  bland  protective  oil  spray  for  the  larynx, 
and  the  avoidance  of  unnecessary  local  applications,  seem  to 
be  the  methods  which  promise  the  best  results  in  the  average 
case.  As  stated  above,  the  improvement  of  the  patient's  gen- 
eral health,  with  its  consequent  increased  resistance  to  the 
disease,  secured  by  sufficient  fresh  air,  food  and  rest,  is,  after 
all,  the  most  essential  factor  in  the  treatment  of  laryngeal 
tuberculosis. 

Fistula  in  Ano.  The  development  of  fistula  in  ano  is  of  con- 
siderable diagnostic  importance,  and  the  presence  of  this  con- 
dition should  at  once  direct  attention  to  the  probable  existence 
of  pulmonarjr  tuberculosis. 

When  this  condition  is  present  in  a  patient  suffering  from 
pulmonary  tuberculosis,  the  value  of  surgical  interference  is 
very  questionable.  It  is  not  an  uncommon  experience  to  find 
an  increased  activity  of  the  pulmonary  process  following,  and 
apparently  caused  by,  operative  measures  applied  for  the  pur- 
pose of  closing  these  fistulse. 

The  presence  of  a. small  fistula  is  not  a  serious  detriment 
to  the  health  or  comfort  of  the  patient,  and  it  will  be  found 
that  they  not  infrequently  heal  under  simple  local  cleanliness 
and  the  general  hygienic  measures  adopted  for  the  arrest  of 
the  pulmonary  process. 

It  has  been  frequently  noted  that  many  cases  of  pulmonary 
tuberculosis  appear  to  do  very  much  better,  so  far  as  their 
general  health  and  pulmonary  process  are  concerned,  as  long 
as  the  fistula  continues  discharging.  When  the  fistula  be- 
comes closed,  without  healing  from  the  bottom  up,  an  exacer- 
bation of  the  pulmonary  disease  frequently  results. 

ASSOCIATED    DISEASES. 

Cardiac  Disease.  For  many  years  the  opinion  was  held 
that  an  antagonism  existed  between  valvular  heart  disease  and 
pulmonary  tuberculosis,  this  belief  being  founded  upon  obser- 
vations made  by  numerous  early  writers,  who  held  that 
phthisis  rarely  occurred  in  subjects  of  valvular  heart  disease, 
or  that  if  it  did  occur  the  pulmonary  process  followed  a  be- 


PULMONARY    TUBERCULOSIS.  469 

nign  course.  More  recently  repeated  ol^scrvations  have  con- 
clusively shown  that  xalvular  cardiac  disease  exerts  very 
little,  if  any,  influence  upon  tuberculosis  of  the  lungs,  either 
as  an  inhibitive  or  as  a  curative  influence,  even  if  there  is  no 
loss  of  compensation.  In  anyone  suft'ering-  from  valvular  dis- 
ease of  the  heart,  one  must  be  extremely  cautious  in  making  a 
diagnosis  of  pulmonary  tuberculosis  solely  upon  the  physical 
signs  in  the  chest.  It  is  not  at  all  uncommon  to  find  localized 
areas  of  congestion,  even  over  the  upper  portions  of  the  left 
lung,  which  suggest  the  presence  of  a  tuberculous  focus. 
When  the  patient  presents,  in  addition,  the  history  of  pro- 
longed cough,  dyspnea,  and  hemoptysis,  the  presence  of  pul- 
monary tuberculosis  is  naturally  suspected.  Where  there  is 
loss  of  compensation,  dilatation  of  the  heart,  or  hydrothorax 
the  diagnosis  of  pulmonary  tuberculosis  should  only  be  made 
in  the  presence  of  irrefutable  evidence,  unless  the  pulmonary 
signs  persist  after  compensation  has  been  restored,  or  the 
condition  of  the  heart  and  pleura  more  nearly  approach  the 
normal. 

The  treatment  of  cardiac  disease  when  associated  with  pul- 
monary tuberculosis  does  not  differ  in  any  way  from  that  of 
the  uncomplicated  cases.  The  use  of  digitalis  is  not  contra- 
indicated,  but  drugs  of  this  type  should  be  administered  with 
caution  in  the  cases  in  which  there  is  a  history  of  hemoptysis. 
In  certain  persons  sufTering  from  hemoptysis,  in  which  there  is 
evidence  of  cardiac  weakness,  the  employment  of  cardiac 
stimulants  not  infrequently  is  followed  by  relief  from  this 
symptom. 

Syphilis.  A  double  infection  wnth  tuberculosis  and  syph- 
ilis is  not  at  all  uncommon,  even  active  tuberculous  disease 
being  found  in  individuals  presenting  evidence  of  lues,  either 
of  the  secondary  or  tertiary  stages.  When  either  the  clinical 
manifestations  or  the  Wassermann  test  calls  for  active  anti- 
syphilitic  treatment,  this  should  be  given  regardless  of  the 
pulmonary  process.  Active  treatment  is  especially  indicated 
when  there  is  distinct  clinical  evidence  of  the  luetic  disease. 

The  presence  of  pulmonary  tuberculosis  is  not  a  contrain- 
dication to  intravenous  medication,  but  it  is  necessarv  to  in- 
ject the  solution  more  slowly,  and  at  the  same  time  to  make 
frequent  examinations  of  the  blood-pressure,  in  order  to  make 


470  DISEASES   OF   THE   RESPIRATORY   SYSTEM. 

s\ire  that  it  does  not  become  unduly  elevated.  Several  ob- 
servers have  shown  that  the  intravenous  injections  of  salvar- 
san  are  not  accompanied  by  a  rise  of  blood-pressure,  but  one 
should  avoid  any  possibility  of  danger  from  this  source. 

There  is  a  widespread  impression  that  iodides  are  danger- 
ous drugs  to  employ  in  pulmonary  tuberculosis,  for  fear  of 
causing  a  breaking  down  of  the  connective  tissue  barrier 
which  may  have  been  established  about  the  tuberculous  focus. 
The  grounds  upon  which  this  is  based  appear  to  be  more 
theoretical  than  real,  but  even  if  this  danger  does  exist  when 
the  patient  is  suffering  from  marked  tertiary  lesions  or  any 
serious  complication  calling  for  the  administration  of  iodides, 
the  pulmonary  process  should  be  ignored,  and  the  risk  taken, 
if  such  exists,  of  causing  a  breaking  down  in  order  to  relieve 
the  patient  from  the  added  aggravation  of  the  secondary 
disease. 

Diabetes.  The  view  has  been  held  for  many  years  that 
diabetes  mellitus  predisposes  to  the  development  of  pulmo- 
nary tuberculosis,  and  that  this  disease  is  the  cause  of  death 
in  a  large  proportion  of  diabetics.  The  proof  submitted  is, 
however,  by  no  means  conclusive  that  tuberculosis  occurs 
more  frequently  in  diabetics  than  in  the  general  population  at 
the  same  age  periods. 

The  treatment  of  diabetes  has  been  so  hopeless  in  the  past 
that  the  appearance  of  glycosuria  in  a  person  suiTering  from 
tuberculosis  was  always  considered  of  a  very  grave  signifi- 
cance. With  the  advent  of  the  Allen  treatment,  which 
promises  so  much  in  diabetes,  the  question  arises  as  to 
whether  the  treatment  is  applicable  in  pulmonary  tuber- 
culosis— whether  a  treatment  based  upon  starvation  is  ap- 
plicable to  a  class  of  cases  in  which  hypernutrition  is  the 
most  important  part  of  the  treatment.  Recent  investigations 
show  that  the  Allen  treatment  may  be  applied  in  the  tuber- 
culous with  decided  benefit,  if  carried  out  with  care  and 
judgment,  and  with  the  patient  under  careful  observation  and 
complete  control ;  in  other  words,  under  the  only  conditions 
under  which  the  Allen  treatment  should  ever  be  employed. 
As  in  nearly  every  other  associated  grave  disease,  it  is  the 
tuberculosis  w^hich  must  be  ignored  when  the  point  is  reached 
where  one  must  decide  as  to  which  process  requires  the  more 


PULMONARY    TUBERCULOSIS.  471 

energ^etic  treatment.  The  general  improvement  which  follows 
relief  from  the  glycosuria  more  than  repays  the  slight  risk 
which  one  runs  by  the  few  days  starvation,  or  the  short  period 
of  limited  food. 

Pregnancy.  Many  tuberculous  women  apparently  suffer 
no  harm  from,  and-  even  appear  benefited  by,  pregnancy,  but 
practically  every  one  is  unfavorably  affected  by  parturition, 
inasmuch  as  childbirth  frequently  leads  to  an  exacerbation 
of  the  tuberculous  disease,  even  when  it  has  been  quiescent 
for  a  considerable  period  of  time.  In  view  of  the  serious  re- 
sults which  may  follow  child-bearing,  when  consulted  by  a 
tuberculous  woman  as  to  the  advisability  of  marrying,  she 
should  be  warned  of  the  dangers  attending  this  function,  un- 
less the  disease  apparently  has  been  cured  for  several  years, 
and  the  greatest  care  is  used  during  pregnancy  and  parturi- 
tion. Many  eminent  authorities  contend  that  the  married 
tuberculous  woman  should  not  only  be  warned  of  the  dangers 
attending  childbirth,  but  should  be  instructed  in  the  meas- 
ures for  preventing  conception. 

The  majority  of  cases  which  call  for  a.dvice  are  tuberculous 
women  who  are  already  pregnant,  and  who  desire  to  know 
whether  any  additional  precautions  are  necessary  to  safe- 
guard their  health.  Many  physicians  insist  upon  emptying 
the  uterus  whenever  there  is  evidence  of  activity  in  the  pul- 
monary process.  The  question  of  whether  pregnancy  should 
be  interrupted  must  be  decided  in  the  individual  case,  depend- 
ing upon  the  general  conditions  under  which  the  patient 
lives,  whether  she  is  able  to  receive  the  care  and  treatment 
necessary  and  has  sufficient  intielligence  to  carry  out  the 
necessary  measures,  whether  there  are  other  children, 
whether  the  disease  is  markedly  active,  and  the  duration  of 
the  pregnancy. 

During  pregnancy  a  tuberculous  woman  should  be  kept 
under  very  careful  observation,  in  order  that  her  general 
nutrition  be  maintained  at  the  highest  possible  level,  and  that 
the  first  indication  of  activity  may  be  detected.  Many  writers 
believe  that  upon  the  first  appearance  of  any  "unfavorable 
symptom  suggestive  of  active  tuberculous  disease,  when  it 
occurs  prior  to  the  fifth  month  of  pregnancy,  the  uterus  should 
be  emptied.    After  the  fifth  month  the  case  should  be  treated 


472  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

expectantly,  and  labor  be  made  as  easy  as  possible,  even 
inducing  premature  labor  two  weeks  before  -term  in  some 
cases. 

Many  women  go  through  pregnancy  without  any  unfavor- 
able symptom  referable  to  the  pulmonary  disease,  only  to  have 
it  become  violently  active  during  or  shortly  following  the 
puerperium.  Every  woman  who  has  suffered  from  tuber- 
culous disease,  no  matter  how  long  it  has  remained  quiescent, 
should  be  treated  as  if  an  active  case  of  tuberculous  disease 
existed,  for  a  period  of  one  to  two  months  following  parturition. 
■  The  development  of  activity  in  the  pulmonary  process  may  be 
so  insidious  as  to  evade  detection  for  a  considerable  period, 
even  when  under  careful  observation.  The  enforced  period 
of  absolute  rest  eliminates  this  danger  as  far  as  it  is  possible  by 
our  present  methods  of  treatment. 

Tuberculous  women  should  not  nurse  their  children,  not- 
withstanding the  disadvantages  of  artificial  feeding,  except  in 
very  exceptional  cases,  and  never  when  the  mother's  sputum 
is  known  to  contain  tubercle  bacilli.  The  extreme  susceptibil- 
ity of  infants  to  bacterial  infections  is  almost  certain  to  lead 
to  an  implantation  from  the  intimate  association  with  the 
mother,  particularly  in  breast-fed  infants,  even  if  the  danger 
of  a  milk-borne  infection  could  be  excluded.  It  has  been 
shown  that  milk  from  a  tuberculous  mother  occasionally  con- 
tains tubercle  bacilli,  and  this  fact  constitutes  an  additional 
risk  to  the  child. 

CHRONIC    NON-TUBERCULOUS    PULMONARY 
INFECTIONS. 

The  chronic  non-tuberculous  pulmonary  infections  have 
been  receiving  more  attention  in  recent  years  than  was  for- 
merly accorded  them,  and  while  evidence  is  accumulating  to 
indicate  that  such  conditions  actually  exist,  it  would  be  pre- 
mature at  this  time  to  describe  definitely  their  frequency, 
pathology,  symptomatology,  diagnosis,  or  treatment.  The 
reported  cases  seem  to  indicate  that  the  general  symptomatol- 
ogy closely  resembles  that  of  tuberculosis,  for  which  they  are 
usually  mistaken,  the  disease  being  accompanied  by  chronic 
cough,  expectoration,  slight  elevation  of  temperature,  and 
gradual    loss    of    weight    and    strength.      Night-sweats    and 


NON-TUBERCULOUS  PULMONARY  INFECTIONS.        473 

hemoptysis  have  been  reported  as  occurring  during  the 
progress  of  the  disease.  Non-tuberculous  infections  of  the 
type  under  discussion  usually  follow  some  acute  infection, 
especially  one  in  which  there  has  been  some  affection  of  the 
respiratory  tract,  or  they  may  result  from  lobar  or  broncho- 
pneumonia, more  commonly  following  repeated  attacks  of 
pneumonia.  It  is  not  uncommon  to  find  a  chronic  cough  and 
expectoration  in  children  who  have  been  the  subject  of  some 
acute  infectious  disease,  such  as  measles,  pertussis,  or  scar- 
latina, or  have  passed  through  an  attack  of  pneumonia.  These 
children  are  usually  underweight,  anemic  and  weak.  On  ex- 
amination they  are  found  to  have  an  elevated  temperature, 
not  confined  to  the  afternoon  but  seemingly  fairly  constant, 
the  pulse  is  rapid,  and  on  examination  of  the  chest  localized 
rales  are  revealed,  confined  to  one  or  the  other  lower  lobes. 
The  rales  may  become  apparent  only  after  cough,  or  as  the 
result  of  change  of  position,  especially  when  the  patient  is 
examined  in  the  inverted  position.  A  moderate  degree  of 
limitation  of  pulmonary  excursion  may  be  present,  with  im- 
pairment on  percussion,  diminished  or  suppressed  breath- 
sounds,  and  slight  increase  or  no  change  in  the  voice-sounds 
over  the  affected  area.  These  signs  may  persist  for  months 
or  even  for  years  with  recurrent  exacerbations  of  the  original 
symptoms.  In  adults  a  similar  condition  may  be  found,  in 
which  one  usually  obtains  a  history  of  cough  and  expectora- 
tion, frequently  dating  back  to  childhood,  the  condition  being 
ascribed  to  an  attack  of  pneumonia  or  to  one  of  the  acute  in- 
fectious diseases. 

The  pathology  of  the  process  has  not  been  definitely  de- 
termined, but  from  the  clinical  study  it  probably  consists  of 
an  interstitial  thickening,  the  result  of  hyperemia  and  cellular 
exudation.  Until  more  is  known  of  the  pathologic  factors  at 
work,  a  doubt  must  remain  as  to  whether  these  cases  should 
not  be  considered  as  early  or  slight  cases  of  bronchiectasis. 
For  the  present  it  would  seem  more  rational  to  consider  them 
as  cases  of  a  definite  pathologic  process,  until  further  evidence 
has  been  collected  to  establish  the  existence  of  a  probable  rela- 
tionship to  any  other  disease. 

The  treatment  apparently  followed  by  the  best  results  is 
that  suggested  for  bronchiectasis,  namely  postural  changes, 


474  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

to  facilitate  the  expulsion  of  the  accumulated  expectoration, 
and  the  upbuilding-  of  the  patient's  general  health  and 
strength.  Further  study  may  confirm  the  finding  that  many  of 
these  cases  are  due  to  specific  bacterial  infection  (influenza 
bacillus  or  streptococcus,  for  example)  in  which  event  bene- 
ficial results  possibly  may  be  obtained  from  the  use  of  bac- 
terial vaccines. 

PULMONARY    CONGESTION. 

Active  congestion  of  the  lungs  may  perhaps  occasionally 
occur  as  a  primary  disease,  but,  as  a  rule,  it  is  secondary  to 
some  other  process,  constituting  the  first  stage  of  pneumonia, 
accompanying  to  a  greater  or  less  extent  all  acute  inflamma- 
tory and  many  tuberculous  processes  in  the  lungs,  pleurisy 
with  effusion;  it  may  also  occur'  in  consequence  of  the  too 
rapid  withdrawal  of  pleural  effusions,  or  from  the  inhalation 
of  irritating  gases  or  fumes.  A  primary  form  has  been 
described  which  has  been  recognized  as  a  distinct  disease 
process  (Woillez's  disease),  which  recent  investigations  indi- 
cate is  probably  merely  an  abortive  type  of  pneumonia. 

The  hyperemic  areas  of  the  lung  are  dark-red  in  color,  of 
somewhat  increased  resistance,  and  diminished  elasticity, 
although  the  pulmonary  tissue  is  still  air-bearing.  The  cut 
surface  exudes  an  increased  amount  of  bloody  fluid,  usually 
dark-red  in  color.  Microscopically,  the  alveoli  are  seen  to 
contain  serous  exudate,  leucocytes  and  desquamated  epi- 
thelial cells,  the  capillaries  being  engorged  with  blood. 

The  passive  form  results  from  some  obstruction  to  the 
flow  of  blood  from  the  lungs  to  the  left  side  of  the  heart,  as  a 
result  of  cardiac  disease,  such  as  mitral  disease,  or  insuffi- 
ciency of  the  left  ventricle,  leading  to  a  damming  back  of  the 
blood  in  the  pulmonary  veins  or  where  some  mechanical  ob- 
struction to  the  flow  of  blood  through  the  pulmonary  veins 
exists,  sucb  as  pressure  from  some  mediastinal  growth,  or 
thrombosis  of  the  veins.  Long  standing  cardiac  disease  may 
result  in  a  chronic  passive  congestion  of  the  lungs  of  an  ex- 
treme grade,  with  the  production  of  certain  changes  in  the 
lung,  described  under  the  name  of  brown  induration.  The 
lungs  are  large,  firm,  inelastic,  rather  fragile,  and  of  a  russet- 


PULMONARY    CONGESTION.  475 

brown  color,  due  to  the  deposit  of  blood-pigment.  The  blood- 
vessels are  usually  engorged,  and  small  parenchymatous 
hemorrhages  may  be  present.  Microscopically,  the  capillaries 
are  dilated,  and  there  are  possibly  small  areas  of  ecchymosis 
and  a  moderate  increase  of  the  interstitial  tissue  containing 
pigment  granules ;  these  are  seen  also  within  the  alveoli, 
either  as  free  particles  or  included  in  epithelial  cells  or  leuco- 
cytes. 

The  symptoms  resulting  from  pulmonary  congestion  are 
cough,  dyspnea,  and  cyanosis.  Cough  is  a  very  frequent 
symptom  and  may  be  unaccompanied  by  expectoration,  or 
with  the  production  of  a  slight  mucoid  material.  The  sputum 
frequently  contains  blood,  in  the  form  of  slight  bloody  streaks, 
bloody  and  frothy  mucus,  or  as  actual  frank  hemorrhages. 
The  pigmented  epithelial  cells  ("Herzfehlerzellen")  are  fre- 
quently present  in  the  sputum.  The  cough  and  expectoration 
may  be  aggravated  or  modified  by  the  development  of  a 
secondary  bronchitis.  The  dyspnea  is  usually  an  early  and 
persistent  symptom,  and  it  may  become  extremely  severe. 
The  reclining  position  usually  intensifies  the  dyspnea  when 
due  to  passive  congestion,  the  relative  relief  in  the  upright 
position  being  quite  a  striking  feature.  Cyanosis  varies 
greatly  iij  these  cases  with  the  degree  of  pulmonary  stasis, 
but  it  is  almost  always  present  to  some  extent. 

Passive  congestion  of  itself  may  give  rise  to  no  physical 
signs  which  can  be  elicited  on  examination  of  the  chest.  The 
presence  of  fluid  in  the  air-passages,  which  usually  accom- 
panies the  process,  gives  rise  to  rales,  as  a  rule  most  marked 
over  the  lower  portions  of  the  lungs.  The  hypostatic  type  of 
passive  congestion  results  from  loss  of  tone  of  the  pulmo- 
nary vessels,  failing  circulation,  and  the  efifects  of  gravity ;  this 
type  of  congestion  is  met  with  in  chronic  debilitating  diseases, 
poisoning,  coma,  old  age,  etc.  In  these  cases  the  dependent 
portions  of  the  lung-  are  the  seat  of  a  congestion  which  is  more 
marked  than  in  the  other  portions.  Hypostatic  pneumonia 
may  develop  in  these  areas  of  congestion  as  the  result  of  bac- 
terial invasion. 

When  the  pulmonary  congestion  develops  suddenlv  from 
rapid  loss  of  cardiac  power,  the  symptoms  usually  are  verv 
severe,  and  the  hard,  dry  cough,  intense  dyspnea,  orthopnea, 


476  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

cyanosis,  and  oppressive  feeling's  in  the  chest  have  led  to  the 
misnomer  of  "cardiac  asthma"  being  applied  to  this  condition. 

TREATMENT. 

The  treatment  of  this  process  depends  upon  the  nature  of 
the  underlying  condition  with  which  it  is  associated.  Where 
cardiac  disease  or  failing  circulation  are  responsible,  diffus- 
ible stimulants  are  often  of  considerable  help.  Much  may  be 
done  to  prevent  the  development  of  congestion  of  the  hypo- 
static type  by  frequent  change  of  position  in  those  in  whom 
it  is  likely  to  occur,  or  by  propping  up  in  the  erect  position. 
In  the  treatment  of  the  aged  for  any  condition  which  may  con- 
fine them  to  bed,  and  in  prolonged  wasting  diseases,  this  pre- 
cautionary measure  should  be  constantly  kept  in  mind.  When 
the  pulmonar}^  engorgement  is  of  a  severe  t}"pe,  and  com- 
plicated by  dilatation  of  the  right  heart,  the  symptoms  may 
become  so  urgent  that  A^enesection  will  be  necessary,  in  order 
to  avert  cardiac  failure. 

In  the  ordinary  type,  dry  cups  to  the  chest,  counter-irrita- 
tion with  mustard  or  turpentine,  diffusible  heart  stimulants, 
expectorants,  diuretics,  and  purgatives  will  usually  meet  the 
requirements.  When  associated  with  or  due  to  some  other 
process,  the  treatment  will  have  to  be  modified  to  meet  the 
existing  conditions. 

PULMONARY    EDEMA. 

The  transudation  of  a  serous  fluid  into  the  alveoli,  bron- 
chioles, and  interstitial  tissues  of  the  lung  may  occur  secon- 
darily to  congestion,  or  as  a  terminal  process  in  death  from 
any  cause.  It  is  rare  to  find  congestion  of  the  lungs  without 
a  certain  amount  of  edema,  irrespective  of  the  cause  of  the 
congestion. 

There  is  a  primary  type  (acute  suffocative  pulmonary 
edema)  which  develops  in  an  acute  manner,  usually  in  sub- 
jects of  arteriosclerosis,  chronic  disease  of  the  heart  or  kid- 
ney, during  the  course  of  acute  infectious  diseases,  or  rarely 
as  an  idiopathic  process.  The  rapid  removal  of  large  collec- 
tions of  fluid  from  the  pleural  space  or  the  peritoneal  cavity 
also  has  in  rare  instances  been  followed  by  acute  p.ulmonary 
edema. 


PULMONARY    EDEMA.  477 

Pulmonary  edema  seems  to  depend  upon  an  increased  pres- 
sure within  the  puhnonary  capillaries,  combined  with  an  in- 
creased permeability  of  the  vascular  walls  of  some  undeter- 
mined nature.  The  appearance  of  the  lungs  varies  with  the 
deg-ree  of  pulmonary  congestion  with  which  it  is  so  very  fre- 
quently associated.  In  addition  to  congestion,  the  lungs  show 
the  presence  of  an  excessive  amount  of  fluid,  which  exudes 
freely  from  the  cut  surface,  and,  microscopically,  the  alveoli 
and  interstitial  tissues  contain  an  excessive  amount  of  serous 
fluid,  in  addition  to  such  changes  as  have  been  described 
under  congestion. 

Edema  of  the  lungs  is  manifested  clinically  by  the  more 
or  less  profuse  expectoration  of  a  frothy  serous  fluid,  rich  in 
albumin,  usually  blood-tinged,  from  the  associated  congestion. 
The  dyspnea  may  be  severe,  the  cough  very  distressing,  and 
cyanosis  of  varying  degrees  of  intensity  is  frequently  present. 
Upon  examination,  fine  moist  rales  are  audible  over  both 
lungs,  or,  if  the  amount  of  serous  exudate  is  excessive,  coarse, 
bubbling  rales  may  replace  or  obscure  the  finer  rales,  in  either 
instance  the  signs  of  moisture  in  the  lungs  being  most  marked 
at  the  bases.  The  breath-sounds  are  usually  suppressed  or 
obscured  by  the  rales,  and  on  percussion  there  may  be  slight 
impairment  of  resonance  at  the  bases,  depending  upon  the 
severity  of  the  process. 

In  acute  pulmonary  edema  the  attacks  usually  are  very 
severe,  coming  on  suddenly,  with  very  slight  or  no  premoni- 
tory signs,  the  patient  being  suddenly  seized  with  intense 
dyspnea,  labored  breathing,  and  orthopnea.  The  cold  ex- 
tremities, free  sweating,  and  cyanosis  indicate  the  grave 
nature  of  the  attack.  The  sense  of  oppression  in  the  chest, 
or  sufi^ocation,  also'  is  usually  present.  The  cough  is  ex- 
tremely distressing,  and  accompanied  by  the  expectoration  of 
a  frothy,  thin,  watery  material,  pinkish  in  color;  ordinarily 
this  fluid  is  moderate  in  amount,  but  it  may  be  so  excessive 
as  to  gush  from  the  mouth,  the  quantity  expectorated  reach- 
ing even  as  high  as  1  or  2  quarts  (1  to  2  1.)  during  the  attack. 
Death  may  result  from  the  first  attack,  although  recoverv 
from  the  initial  edema  is  more  common,  to.  be  followed  bv 
repeated  attacks  until  death  intervenes,  either  during-  the  at- 
tack or  from  some  associated  condition  between  attacks. 


478  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

TREATMENT. 

The  treatment  of  edema  of  the  lungs  depends  upon  the 
nature  of  the  underlying  cause,  as  described  under  Conges- 
tion. In  the  acute  suffocative  types,  due  to  cardio-renal,  or 
cardio-vascular  disease,  an  efifort  must  be  made  to  re-establish 
the  balance  between  the  working  power  of  the  two  sides  of 
the  heart,  the  loss  of  which  is  a  most  important  if  not  the 
only  factor  involved  in  the  development  of  the  pulmonary 
edema.  The  lost  strength  of  the  left  ventricle  is  the  essential 
feature  of  the  process,  although  the  underlying  cause  may 
be  disease  of  the  coronary  arteries,  arterial  hypertension,  or  a 
combination  of  both.  To  restore  the  circulatory  equilibrium  is 
a  far  from  easy  matter,  requiring  a  careful  study  of  the  nature 
of  the  pathologic  process  responsible  for  the  disproportion  be- 
tween the  action  of  the  right  and  left  sides  of  the  heart. 

Before  resorting  to  the  use  of  cardiac  stimulants  it  is  ad- 
visable first  to  try  the  effect  of  such  general  measures  as  rest 
and  quiet,  counter-irritation,  dry  cups  to  the  chest,  hot  packs 
to  the  extremities,  and  increased  elimination  by  the  kidneys, 
skin,  and  intestinal  tract.  There  is  some  question  of  the 
advisability  of  using  morphine  in  these  acute  cases,  but  it  may 
be  employed  in  combination  with  atropine,  if  care  is  exer- 
cised. When  cyanosis  is  extreme,  oxygen  inhalations  may  be 
found  useful.  Cardiac  stimulants  require  very  careful  hand- 
ling in  this  condition,  to  avoid  doing  more  harm  than  good. 
When  arterial  hypertension  is  apparently  responsible  for  the 
left  ventricular  failure,  relief  may  be  obtained  by  the  employ- 
ment of  strophanthin  and  nitroglycerin  or  am3^1  nitrite.  In 
the  event  of  failure  from  the  measures  suggested,  it  may 
become  necessary  to  resort  to  digitalis,  camphor,  ether,  am- 
monia, and  caffeine,  or  if  signs  of  enlargement  of  the  right 
heart  develop,  with  marked  cyanosis,  venesection  may  be 
necessary  to  relieve'  the  immediate  dangers  of  a  fatal  ter- 
mination. 

PULMONARY    ABSCESS. 

Abscess  of  the  lung  may  arise  from  disease  of  the  lungs, 
bronchi,  or  pleura,  from  the  extension  of  a  suppurative  process 
in  neighboring  organs,  or  by  metastasis  from  a  septic  process 


PULMONARY    ABSCESS.  479 

in  some  remote  portion  of  the  body.  The  disease  which  seems 
to  be  most  frequently  responsible  for  their  production  is  lobar 
pneumonia ;  bronchopneumonia  appears  to  be  a  rather  un- 
common cause  when  considered  in  its  primary  forms.  When 
bronchopneumonia  results  from  the  aspiration  ,  of  foreign 
bodies,  or  arises  from  bronchiectasis,  etherization,  or  putrid 
bronchitis,  it  probably  plays  a  prominent  role  in  the  forma- 
tion of  the  abscesses  resulting  from  such  conditions.  The 
abscesses  arising  from  localized  suppurative  processes  in  the 
pleura  probably  occur  more  frequently  than  is  generally  sup- 
posed, although,  in  the  majority  of  cases,  it  is  extremely 
difficult  to  say  whether  the  pleural  collection  of  pus  has  ex- 
tended into  the  lung,  or  the  pulmonary  abscess  has  extended 
to  the  pleura.  Necrosis  of  the  vertebrae,  suppuration  of  the 
bronchial  glands,  or  septic  processes  in  the  upper  abdominal 
cavity  may  extend  directly  to  the  lung,  with  the  formation  of 
abscesses.  Septic  thrombi  from  processes  in  other  parts  of 
the-  body  may  be  carried  by  the  blood-stream  to  the  lung, 
where  abscesses  may  arise  at  the  point  where  the  emboli  find 
lodgment,  from  a  breaking  down  of  the  septic  infarct.  The 
abscesses  which  may  arise  in  the  course  of  pulmonary  tuber- 
culosis have  been  considered  under  another  heading  (see  p. 
372),  also  those  due  to  streptothricosis,  actinomycosis,  syph- 
ilis, and  aspergillosis. 

Abscess  may  occur  in  any  part  of  the  lung,  although  the 
lower  portions  are  more  frequently  affected  than  the  upper, 
usually  being  situated  near  the  pleura  (except  those  due  to 
foreign  bodies,  bronchiectasis,  etc.).  The  amount  of  inflam- 
matory exudate  or  induration  in  the  surrounding  lung  tissue 
depends  upon  the  length  of  time  the  abscess  has  been  present ; 
in  the  earlier  cases  the  pneumonia-like  process  is  more  exten- 
sive and  is  not  sharply  defined,  gradually  shading  oft"  into 
normal  lung  tissue.  When  the  abscess  is  of  long  standing, 
this  surrounding  zone  usually  undergoes  fibroid  change,  with 
the  formation  of  a  relatively  narrow,  dense,  scar-like  wall 
about  the  abscess  cavity. 

The  pulmonary  abscesses  have  the  appearance  of  grayish, 
yellowish,  greenish,  or  reddish-brown  areas,  which  contain 
varying  amounts  of  pus.  The  cavities  vary  greatly  in  size, 
from  minute  microscopic  spaces  to  the  dimensions  of  an  entire 


480  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

lobe.  They  may  occur  singly  or  as  multiple  abscesses,  either 
in  close  proximity  or  widely  separated.  In  recently  formed  or 
rapidly  developing-  cavities  the  walls  are  usually  rough,  irreg- 
ular, and  necrotic,  and  not  sharph-  defined  from  the  surround- 
ing lung  tissue,  which  is  almost  universall}-  inflamed.  In 
older  processes  the  surface  of  the  cavity  usually  is  gray, 
whitish,  brown,  or  even,  black,  and  usually  smooth,  with  slight 
irregularities,  or  occasionalK'  lined  with  trabecules.  The  wall 
is  dense  and  firm  from  the  formation  of  connective  tissue,  and 
of  varying  thickness.  The  zone  of  inflammation  surrounding 
the  abscess  also  may  undergo  organization  with  the  forma- 
tion of  a  dense,  firm,  airless  tissue.  The  older  cavities  may 
not  contain  pus,  for  the  contents  may  be  evacuated  through 
the  bronchi.  AMien  present  the  pus  may  be  odorless,  al- 
though usually  it  has  a  sweetish,  sour,  or  foul  odor. 

INIicroscopic  examinations  maj-  reveal  exceedingly  minute 
areas  in  which  pus  cells  replace  the  normal  alveolar  tissue  of 
the  lung.  These  areas. ma}-  undergo  a  healing  process,  with 
the  complete  restoration  of  function,  or  develop  into  well- 
marked  abscess  cavities.  These  microscopic  abscesses  are 
not  uncommon  in  both  lobar  and  bronchopneumonia.  When 
there  is  distinct  abscess  formation,  the  walls  are  infiltrated 
with  pus  cells,  which  extend  into  the  surrounding  lung  tissue. 
The  contents  of  the  lung  cavity  consist  of  detritus,  pus  cells, 
bacteria,  shreds  of  broken  down  lung  tissue,  and  elastic  fibers. 
In  the  older  abscesses  the  walls  of  the  cavity  and  the  sur- 
rounding tissue  show  evidence  of  new  connective  tissue  for- 
mation, in  the  interalveolar,  interlobar,  peribronchial,  and 
perivascular  tissue.  This  formation  of  fibrous  tissue  ma}'  be 
so  dense  as  to  cause  complete  obliteration  of  the  alveoli  in  the 
immediate  neighborhood  of  the  abscess. 

The  presence  of  an  abscess  should  be  suspected  in  any 
case  of  lobar  pneumonia  in  which  the  elevation  of  tempera- 
ture persists  beyond  the  ordinary  time  for  it  to  decline,  and 
in  which  the  expectoration  becomes  purulent,  or  the  area  of 
consolidation  fails  to  resolve.  At  this  time  no  definite  physical 
signs  may  be  present,  the  general  condition  of  the  patient  and 
the  irregular  temperature  suggesting  empyema,  caseous  pneu- 
monia, or  abscess.  The  signs  of  a  cavity  may  appear  after 
the   patient   has   suddenly   expectorated   a  large    quantity   of 


PULMONARY    ABSCESS.  481 

purulent  material.  This  tendency  to  expectorate  suddenly  a 
large  amount  of  purulent  material  at  varying  intervals  is 
probably  the  most  suggestive  symptom  of  abscess  of  the 
lung,  the  evacuation  of  its  contents  being  induced  by  change 
of  position,  coughing,  laughing,  or  sneezing  as  in  bronchiec- 
tasis. The  symptoms  of  pulmonary  abscess  may  present  no 
special  characteristic  to  suggest  the  presence  of  such  a 
process.  This  is  particularly  true  of  those  abscesses  develop- 
ing in  the  course  of  inflammatory  diseases  of  the  lungs,  or  as 
the  result  of  an  extension  of  a  suppurative  process  to  the  lung. 

The  purulent  material  is,  as  a  rule,  not  particularly  offen- 
sive unless  a  certain  amount  of  gangrene  is  present,  but  this 
rule  is  not  absolute,  as  the  pus  may  be  extremely  foul.  The 
quantity  varies  greatly,  is  usually  of  a  greenish  color,  and  on 
standing  has  a  tendency  to  separate  into  three  layers,  with  a 
heavy  layer  of  pus  at  the  bottom,  a  zone  of  foamy  mucus  on 
top,  and  a  fairly  clear  or  cloudy  yellowish  stratum  between. 
This  tendency  of  the  pus  to  form  three  layers,  while  very  sug- 
gestive, is  not  absolutely  characteristic  of  abscess,  as  it  may 
also  occur  in  material  from  a  bronchiectatic  cavity,  or  in  an 
empyema  which  has  been  evacuated  through  a  bronchus. 

The  finding  of  elastic  tissue  in  the  pus,  especially  when  it 
shows  a  reticulated  formation  or  alveolar  arrangement,  is 
indicative  of  a  breaking  down  of  the  lung  tissue,  strongly  sug- 
gestive of  abscess.  Care  must  be  exercised  in  examining  the 
sputum  for  elastic  fibers  to  exclude  food  particles,  as  they 
constitute  a  not  uncommon  source  of  error.  The  elastic  tissue 
may  be  visible  to  the  naked  eye,  when  the  sputum  is  spread 
in  a  thin  layer  .over  a  black  background,  as  small  yellowish 
masses.  A  better  method  for  studying  this  tissue  is  by 
diluting  the  sputum  with  twenty  volumes  of  water,  to  which 
a  few  drops  of  a  saturated  solution  of  potassium  hydroxide 
have  been  added.  The  mixture  is  warmed  until  the  sputum 
is  dissolved,  and  the  sediment  obtained  by  centrifugation  is 
mounted  upon  a  slide  and  stained  with  Weigert's  elastic  tis- 
sue stain.  By  this  method  the  elastic  tissue  fibers  are  stained 
a  very  dark  blue  or  black,  which  permits  accurate  study  of 
their  alveolar  arrangements,  and  avoids  any  possibility  of 
confusing-  them  with  other  constituents  of  the  sputum,  which 
occasionally  may  cause  some  confusion. 


4B2  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

The  physical  signs  vary  very  much,  and  usually  are  those 
indicative  of  dense,  inflammatory  exudate  rather  than  cavity, 
especially  v^hen  the  condition  is  fairly  recent.  The  signs  of 
cavity  may  be  elicited  if  the  chest  is  examined  shortly  after 
the  expectoration  of  a  large  quantity  of  pus.  The  abscesses 
which  are  overlooked  are  those  in  v^^iich  evidences  of  cavity 
have  been  lacking,  and  on  that  ground  the  possibility  of  cavity 
ignored.  It  may  be  stated  that  definite  signs  of  cavity  with 
t3^mpany,  cavernous  or  amphoric  breathing,  bubbling  metal- 
lic rales,  and  whispering  pectoriloquy  over  a  recent  abscess  are 
the  exception  rather  than  the  rule. 

A  localized  collection  of  rales,  dullness  on  percussion,  and 
slight  bronchovesicular  breathing  may  suggest  the  presence  of 
abscess,  such  signs  being  due  to  the  consolidation  or  cellular 
infiltration  of  the  pulmonarj^  tissue  in  the  immediate  neighbor- 
hood of  the  abscess.  AMien  the  abscess  is  large  and  filled  with 
fluid  there  ma}'  be  absent  or  diminished  breath-  and  voice- 
sounds,  in  addition  to  the  dullness,  over  the  area-  affected. 
With  the  evacuation  of  the  pus,  the  signs  of  cavity  may  ap- 
pear, only  to  disappear  as  the  fluid  reaccumulates. 

The  study  of  the  case  by  means  of  stereoscopic  skiagrams 
may  be  of  considerable  service  in  locating  the  abscess  cavity, 
especially  when  it  is  of  long  standing.  In  recent  abscesses 
the  shadow  corresponds  to  the  physical  signs  indicating  an 
area  of  infiltration  rather  than  a  cavity,  on  account  of  the 
dense  zone  of  infiltration  with  which  the  cavit}^  usually  is 
surrounded.  This  method  of  study  has  the  additional  ad- 
vantage of  revealing  the  presence  of  foreign  bodies,  which 
may  be  responsible  for  the  abscess  formation,  and  plates  taken 
immediately  after  the  expectoration  of  large  quantities  of  pus 
may  reveal  the  presence  of  the  abscess  cavity.  Abscesses  of 
long  standing  may  be  indicated  upon  the  plates  as  more  or  less 
irregularly  rounded  clear  spaces  surrounded  by  a  definite  dark 
shadow  due  to  the  surrounding  dense  connective  tissue. 

While  complete  recovery  from  undoubted  pulmonary  ab- 
scesses have  been  recorded,  this  is  not  the  rule,  the  patient 
more  commonl}-  continuing  to  cough  and  expectorate  pus 
everx  after  the  acute,  severe  symptoms  subside,  the  fibroid 
changes  induced  in  the  surrounding  lung  tissue  usually  pre- 
venting a  complete  return  to  normal. 


PULMONARY    ABSCESS.         •  483 

TREATMENT. 

The  treatment  of  the  acute  condition  consists  in  absolute 
rest  in  bed,  fresh  air  and  nourishing  food  (see  Tuberculosis, 
p.  409).  Care  must  be  exercised  to  prevent  the  swallowing 
of  the  purulent  expectoration,  and  the  patient  warned  of  the 
necessity  of  not  allowing  any  of  the  expectoration  to  gain 
entrance  to  the  esophagus.  A  mouth-wash  should  be  pro- 
vided, to  keep  the  mouth  and  throat  thoroughly  cleansed.  In 
some  cases  the  patient  unconsciously  assumes  the  position 
which  favors  drainage,  while  others,  in  order  to  prevent  cough 
and  expectoration,  habitually  lie  in  that  position  which  helps 
to  retain  the  purulent  contents  of  the  abscess.  Various  posi- 
tions in  bed  should  be  tried,  to  determine  the  posture  most 
likely  to  favor  the  evacuation  of  the  pus.  When  this  has  been 
determined  the  patient  should  be  instructed  to  assume  such 
a  position  at  frequent  intervals  during  the  day,  so  that  the 
accumulation  of  large  quantities  of  pus  may  be  avoided. 

Various  medicinal  agents  may  be  employed  which  favor  the 
expectoration  of  the  purulent  material,  such  as  ammonium 
chlorid,  creosote,  oil  of  eucalyptus,  and  oil  of  turpentine, 
especially  if  the  sputum  is  very  ofifensive.  Steam  inhalations 
may  also  give  considerable  relief,  especially  when  combined 
with  various  medicinal  agents  (see  Bronchiectasis,  Acute  and 
Chronic  Bronchitis,  pp.  330-344).  The  derivatives  of  opium 
should  be  absolutely  avoided,  except  when  there  is  a  constant, 
dry,  unproductive  cough,  in  which  event  it  may  be  necessary  to 
give  morphin  ^  grain  (0.008  Gm.),  heroin  %2  grain  (0.0054 
Gm.),  or  codein  ^4  grain  (0.016  Gm.),  the  doses  being  re- 
peated, if  necessary,  to  secure  sufficient  sleep. 

In  the  acute  cases,  when  the  patient  does  not  show  signs  of 
marked  sepsis,  when  the  pus  is  not  foul,  and  when  the  physical 
signs  and  sputum  examinations  indicate  very  little  breaking 
down  of  the  lung  tissue,  the  medical  treatment  suggested  may 
be  tried  for  several  weeks,  in  the  hope  of  securing  a  spon- 
taneous cure. 

When  the  pus  is  foul,  and  there  is  evidence  of  an  active 
destructive  process  in  the  lung,  the  advisability  of  surgical 
interference  must  be  considered. 

Surgical  treatment  is  not  indicated,  as  a  rule,  in  abscess 
cavities  of  long  standing,  and  in  multiple,  widely-separated 


484  DISEASES    OF   THE   RESPIRATORY   SYSTEM. 

abscesses,  although  the  question  is  one  to  be  decided  in  the 
individual  case.  Recently  very  favorable  results  have  been 
reported  from  the  use  of  artificial  pneumothorax  in  the  treat- 
ment of  pulmonar}-  abscesses,  instead  of  the  open  operation, 
with  direct  incision  and  drainage  of  the  abscess  cavity.  The 
amount  of  induration  about  the  abscess  and  the  duration  and 
location  of  the  process  must  be  taken  into  consideration  in 
deciding-  between  these  two  methods  of  treatment. 

In  cavities  of  very  long  standing,  attended  by  marked 
symptoms  of  an  unfavorable  character,  it  may  be  necessary  to 
consider  the  advisability  of  extensive  resection  of  the  ribs, 
or  even  pulmonary  resection. 

The  results  of  operative  interference  in  cases  of  pulmonary 
abscess  are  more  saisfactory  than  formerly,  owing  to  im- 
proved technic  and  the  newer  methods  for  the  prevention  of 
pulmonary  collapse  when  the  chest  wall  is  opened.  The  use 
of  stereoscopic  skiagraphs  has  also  proven  of  assistance  in  the 
surgical  treatment  of  these  cases  by  permitting  a  more  exact 
localization  of  the  abscess  in  obscure  cases  than  was  formerly 
possible. 

PULMONARY    GANGRENE. 

What  has  been  said  in  regard  to  the  etiology  of  abscess 
applies  equally  to  gangrene,  except  that  the  latter  is  less  fre- 
.  quent  as  a  result  of  lobar  pneumonia,  and  is  more  likely  to 
be  due  to  the  aspiration  of  putrefying  material,  such  as  may 
occur  during  operations  upon  the  nose,  mouth,  or  throat, 
while  the  patient  is  under  ether,  or  as  a  result  of  diphtheria, 
cancer  of  the  tongue  or  jaw,  or  new  growths  of  the  esophagus. 
While  numerous  bacteria  have  been  described  as  the  cause  of 
gangrene,  this  etiologic  relationship  has  never  been  definitely 
proven.  Gangrene  of  the  lung  is  consequent  to  serious  inter- 
ference with  the  blood-suppl}-  of  a  portion  of  the  lung-,  such 
as  thrombosis  caused  by  bacterial  infection  or  embolism,  or 
by  infection  with  micro-organisms  of  a  peculiarly  destructive 
or  putrefactive  type.  ^Mlile  an  entire  lobe  or  greater  portion 
of  a  lobe  may  share  in  the  gangrenous  process,  the  small 
localized  form  is  more  common,  vars'ing  in  size  from  a  pea 
to  an  orange.  Thev  varv  in  color  from  a  greenish  gray  to 
greenish  brown  or  black,  the  tissue  being  very  fragile,  pulpy, 


PULMONARY    GANGRENE.  485 

and  may  contain  cavities.  The  odor  is  extremely  foul.  The  cavi- 
ties usually  have  rough,  shreddy  w^alls,  and  not  infrequently 
contain  fluid  of  a  greenish  or  brow^nish  color,  with  a  very 
offensive  odor.  The  lumen  of  the  cavities  may  be  traversed,  or 
the  walls  lined,  with  bronchi  or  blood-vessels.  The  gangren- 
ous areas  are  surrounded  by  a  zone  of  hyperemia  or  con- 
solidation, beyond  which  the  pulmonary  tissue  is  edematous. 
Occasionally  the  process  may  be  walled  off  from  the  sur- 
rounding tissue  with  the  formation  of  a  cavity,  but  in  the 
majority  of  cases  the  process  continues  to  spread.  When 
studied  under  the  microscope  the  alveoli  are  found  to  contain 
desquamated  epithelial  cells,  serum,  numerous  erythrocytes, 
a  few  leucocytes,  and  a  small  amount  of  fibrin.  The  forma- 
tion of  connective  tissue  may  be  present  in  the  surrounding 
lung,  similar  to  the  process  accompanying  pulmonary  abscess. 
What  has  been  said  of  pulmonary  abscess  in  regards  to  the 
location  and  number  of  the  lesions,  and  the  changes  in  the 
surrounding  lung  tissue  and  pleura,  applies  equally  to  gan- 
grene. The  clinical  symptoms  of  the  two  processes  are  almost 
identical,  except  that  in  gangrene  the  depressing  eft'ect  upon 
the  patient's  general  health  is  much  more  marked,  and,  as  a 
rule,  the  prostration  being  more  severe.  The  sputum  usually 
is  more  offensive  than  in  abscess,  and  more  likely  to  be  of  a 
dark,  chocolate-brown  color,  due  to  the  admixture  with  blood. 
At  one  time  the  presence  of  elastic  fibers  in  the  sputum  was 
considered  as  indicative  of  abscess  rather  than  gangrene,  but 
the  results  of  further  study  have  shown  this  assumption  to  be 
unwarranted.  Small  masses  or  shreds  of  the  lung  paren- 
chyma are  more  commonly  present  in  the  material  expec- 
torated in  gangrene  than  in  abscess  of  the  lung. 

The  clinical  differentiation  between  abscess  and  gangrene 
rests  upon  the  odor  of  the  expectorated  material  in  the  major- 
ity of  instances,  w^hich  gives  one  some  conception  of  how 
closely  the  two  conditions  resemble -one  another,  and  how 
inadequate  are  our  present  means  of  differentiation. 

The  treatment  of  gangrene  differs  in  no  way  from  that  of 
abscess,  except  that  as  the  process  is  of  a  more  acute  and 
malignant  character  than  many  abscesses,  one  is  not  justified 
in  adopting  any  plan  of  expectant  treatment  for  any  length  of 
time.     The  diagnosis  of  gangrene  calls  for  active  and  radical 


486  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

treatment,  being  influenced  to  a  certain  degree  by  the  amount 
of  lung  tissue  involved  and  the  etiologic  factor  responsible 
for  the  condition  in  the  individual  case. 

PNEUMOCONIOSIS. 

The  inhalation  of  various  metallic  and  mineral  dusts, 
which  are  either  expectorated  or  deposited  in  the  tissues  of  the 
lungs,  may  give  rise  to  very  annoying  S3'mptoms,  due  to 
mechanical  irritation  by  the  minute  particles,  but  the  most 
serious  result  of  such  inhalations  is  the  irritation  and  inflam- 
mation induced  thereby,  which  make  the  subject  susceptible 
to  other  infections  of  the  lungs.  The  various  dusts  which 
may  give  rise  to  pulmonary  symptoms  cannot  be  considered  in 
detail  in  a  work  of  this  kind,  as  such  a  study  would  include 
an  exhaustive  review  of  the  working  conditions  in  nearly 
every  trade.  The  dusts  usually  responsible  for  pneumo- 
coniosis may  be  conveniently  grouped  under  the  headings  of 
coal  (anthracosis) ,  metallic  (siderosis),  and  stone  (chalicosis 
and  silicosis).  The  lungs  of  all  inhabitants  of  large  cities  and 
those  living  near  manufacturing  plants  burning  coal  as  a  fuel 
show  pigmentation  of  the  pulmonary  tissue  with  carbon-par- 
ticles to  a  greater  or  less  extent.  Carbon  deposits  in  the  lungs 
of  sufficient  extent  or  degree  to  warrant  the  name  of  antra- 
cosis  are  found  only  among  coal-miners,  coal-heavers,  and 
men  in  similar  occupations.  The  metallic  dusts  are  respon- 
sible for  pneumoconiosis  in  workers  whose  occupation  ex- 
poses them  to  the  inhalation  of  finely  divided  particles  of 
steel,  iron,  tin,  and  similar  metals,  commonly  consequent  to 
the  trades  of  grinding,  filing,  and  polishing.  The  trades  of 
stone-cutting,  stone-crushing,  blasting,  and  pottery  work  are 
productive  of  the  large  majority  of  pneumoconiosis  due  to  par- 
ticles of  stone.  The  inhalation  of  vegetable  or  animal  fibers, 
such  as  hair,  wool,  flax,  cotton,  flour,  cereals,  and  sawdust, 
while  producing  very  persistent  irritation  of  the  air-passages, 
is  not  so  likely  to  induce  secondary  infections. 

The  foreign  particles  may  be  deposited  in  the  lungs  in 
enormous  quantities,  without  causing  any  symptoms  or 
changes  in  the  lungs  other  than  those  due  to  their  presence, 
such  as  color  changes  and  grittiness. 


PNEUMOCONIOSIS.  487 

When  changes  in  the  lungs  do  occur  they  are  not  in  any- 
way pecuHar  or  characteristic,  for  they  include  bronchitis, 
chronic  induration,  fibrosis,  emphysema,  bronchiectasis,  ab- 
scess, adhesive  pleurisy,  and  enlarged  bronchial  glands,  either 
singly  or  in  various  combinations.  The  principal  danger  from 
dusty  occupations  apparently  does  not  lie  in  the  invasion  of 
the  lung  by  dust  particles  themselves,  but  in  the  infection 
of  the  lung  with  various  bacteria,  favored  by  the  irritation 
resulting  from  the  dust.  Dusty  occupations  predispose  to 
diseases  of  the  bronchopulmonary  system,  as  has  been  re- 
peatedly shown  by  morbidity  and  mortality  statistics.  Among 
workers  in  dusty  trades  and  occupations  it  has  been  repeatedly 
shown  that  the  deaths  from  pulmonary  tuberculosis  are 
greatly  in  excess  of  the  average,  with  the  exception  of  those 
working  in  coal-dust.  This  relative  infrequency  of  pulmonary 
tuberculosis  among  both  soft  and  hard  coal  miners  has  never 
been  satisfactorily  explained,  although  the  truth  of  the  obser- 
vation has  been  repeatedly  confirmed. 

The  clinical  picture  depends  entirely  upon  the  nature  of 
the  changes  set  up  in  the  lung  as  a  result  of  the  inhalation  of 
the  dust,  the  symptoms  being  the  same  as  in  bronchitis,  bron- 
chiectasis, and  so  forth,  otherwise  acquired,  in  which  dust  is 
not  in  any  way  concerned  in  the  etiology.  The  average  case 
in  the  early  stages  presents  symptoms  of  bronchitis,  either 
with  or  without  emphysema,  the  more  marked  conditions, 
such  as  bronchiectasis  and  abscess,  being-  usually  found  in 
those  cases  of  long  standing-  with  excessive  deposits  in  the 
lungs.  When  the  particles  inhaled  have  not  led  to  any  change 
in  the  bronchi  or  lungs,  examination  of  the  chest  may  be 
negative.  The  only  symptom  which  is  at  all  characteristic  or 
peculiar  to  pneumoconiosis  is  that  due  to  the  presence  of  the 
foreign  material  in  the  sputum.  The  sputum  may  be  black 
from  the  presence  of  coal-dust,  soot,  charcoal,  or  minerals,  or 
it  may  contain  finely  divided  particles  of  stone,  metal,  or  the 
various  organic  substances  responsible  for  the  condition.  A 
microscopic  examination  of  the  sputum  is  essential  for  the 
recognition  of  the  foreign  particles,  which  may  be  free  or 
included  within  leucocytes  or  epithelial  cells.  IMicroscopic 
chemical  tests  may  be  necessary  to  identify  absolutely  the 
various  metallic  dusts,  coal,  or  stone  particles. 


488  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

Prevention  of  the  disease  by  adopting  such  measures  as 
will  prevent  the  inhalation  of  the  dusts  is  the  procedure  which 
promises  much,  if  it  is  carried  out  carefully  and  intelligently. 
The  wearing  of  respiratory  masks,  mechanical  suction  de- 
vices in  the  workshop,  or  such  improvements  in  various 
manufacturing  processes  as  will  obviate  the  necessity  of  ex- 
posing the  workman  to  the  dusts,  are  being  more  and  more 
generally  adopted  in  the  large  plants.  The  economic  factors 
involved  have  interfered  with  their  more  general  adoption, 
although  many  states  have  enacted  legislation  which  make 
certain  protective  measures  compulsory. 

As  the  secondary  infections  incident  to  these  dust  diseases 
play  such  an  extremely  important  role  in  the  production  of 
the  pathologic  changes  in  the  bronchi  and,  lungs,  it  is  ex- 
tremely important  that  the  general  hygiene  of  such  workshops 
where  dust  is  prevalent  should  be  maintained  at  a  very  high 
level.  Sunshine,  fresh  air,  and  cleanliness  in  the  workrooms 
will  go  far  toward  overcoming  the  development  of  disease 
from  the  inhalation  of  dusts. 

TREATMENT. 

The  treatment  of  the  condition  other  than  by  the  removal 
of  the  patient  from  exposure  to  the  causative  factor  is  purely 
symptomatic.  The  prevention  of  further  inhalation  of  dust  is 
absolutely  essential,  and  while  it  usually  entails  change  of 
occupation,  this  is  not  necessarily  always  true.  Where  the 
irritation  from  the  dust  particles  has  given  rise  to  secondary 
infection,  of  which  tuberculosis  is  one  of  the  most  frequent, 
the  treatment  should  be  directed  toward  correcting  or  over- 
coming the  secondary  process,  in  addition  to  the  removal  of 
the  primary  cause.  The  treatment  of  such  conditions  as  bron- 
chitis, emphysema,  bronchiectasis,  induration,  and  abscesses 
are  considered  in  detail  in  the  sections  dealing  with  these  con- 
ditions, and  the  medical  care  of  these  processes  when  result- 
ing from  dust-inhalation  does  not  differ  in  any  way  from  that 
which  is  indicated  when  dust  is  not  a  factor. 

There  is  no  method  of  treatment  available  at  the  present 
time  for  the  actual  removal  of  the  particles  of  foreign  material 
from  the  lungs  and  bronchi,    The  majority  of  cases  are  mater- 


PULMONARY   SYPHILIS.  489 

lally  benefited  by  improvement  of  their  general  health  result- 
ing from  such  measures  as  have  been  recommended  for 
tuberculosis. 

PULMONARY    SYPHILIS. 

The  pulmonary  manifestations  of  hereditary  syphilis  are 
chiefly  of  interest  to  the  pathologist.  This  is  especially  true 
when  the  lesion  in  the  lung  takes  the  form  of  "white  pneu- 
monia," which  only  occurs  in  its  true  form  in  stillborn  chil- 
dren or  in  those  living  but  a  short  time,  usually  being  accompanied 
by  a  marked  evidence  of  a  general  luetic  infection.  Gummata 
and  interstitial  pneumonic  processes  also  may  occur  in  the 
congenital  form  of  syphilis,  the  latter  rarely  being  a  single 
process,  for  more  commonly  it  is  associated  with  one  of  the 
other  manifestations  of  this  disease.  The  only  clinical  inter- 
est attached  to  the  various  ways  in  which  syphilis  may  affect 
the  lungs  in  the  congenital  form  of  the  disease  lies  in  the  pos- 
sibility of  pulmonary  involvement  in  an  infant  showing  evi- 
dence of  a  systemic  infection  with  this  disease.  In  the 
acquired  form,  on  the  other  hand,  the  syphilitic  processes  of 
the  lungs  are  of  considerable  clinical  importance,  as  they  may 
be  the  only  evidence  of  the  general  infection,  and  upon  their 
recognition  depends  the  establishment  of  a  correct  diagnosis, 
with  its  definite  indication  of  the  appropriate  treatment. 

A  form  of  bronchial  catarrh  described  by  some  of  the  early 
writers  was  believed  to  be  syphilitic  in  its  nature,  occurring 
during  the  secondary  stage  of  the  disease.  With  this  one  pos- 
sible exception,  the  pulmonary  manifestations  of  acquired 
syphilis  are  an  accompaniment  of  the  tertiary  stage.  Accord-, 
ing  to  numerous  researches,  the  lungs  are  very  rarely  the  seat 
of  syphilitic  disease,  and  while  gummata  or  ulceration  of  the 
trachea  or  bronchi  may  occur  more  frequently  than  actual 
disease  of  the  lungs,  even  these  are  far  from  common  findings. 
Stenosis  of  the  trachea  or  bronchi  may  result  from  the  con- 
tractions resulting  from  syphilitic  infections. 

The  gummata  which  develop  in  the  lung  vary  in  size  from 
minute  nodules  to  masses  the  size  of  a  walnut,  and  are  usually 
located  near  the  pulmonary  root,  although  they  may  be  found  in 
any  part  of  the  lung,  the  apex  being  the  least  frequent  portion 


490  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

affected.  In  association  with  the  gummata  there  may  be  fre- 
quently present  a  diffuse  fibroid  induration  of  the  lung.  In  the 
early  stages  gummata  of  the  lungs  have  been  described  as 
yellowish  in  color,  soft,  irregular,  and  surrounded  by  a  zone 
of  pale  red  or  grayish  tissue,  later  becoming  reddish,  gray, 
yellow,  or  white.  The  gumma  may  undergo  fatty  degenera- 
tion, connective  tissue  formation,  or  even  caseation.  The 
formation  of  a  capsule  as  a  result  of  inflammatory  changes  in 
the  surrounding  tissue,  and  the  evacuation  of  the  necrotic 
tissue  resulting  in  cavity  formation  has  been  described,  but 
such  changes  are  exceedingly  rare.  The  tough  connective 
tissue  scars  occasionally  found  in  the  lungs  are  believed  to  be 
in  some  instances  a  manifestation  of  syphilitic  disease. 

Microscopic  examination  reveals  connective  tissue  cell 
proliferation  in  the  interlobular,  perivascular  or  peribronchial 
tissue,  or  the  tissue  may  be  so  necrotic  as  to  make  it  impos- 
sible to  recognize  the  different  elements.  The  alveoli  and 
alveolar  walls  in  the  region  immediately  adjacent  to  the 
gumma  contain  an  excess  of  proliferated  epithelial  cells,  and 
bands  of  connective  tissue  may  extend  outward  from  the  mass 
into  the  surrounding  tissues.  Marked  changes  usually  occur 
in  the  blood-vessels,  with  thickening-  of  the  walls,  the  adven- 
titia  being  mainly  affected,  with  occasional  changes  in  the 
media,  or  even  ini  the  intima.  While  the  Spii  ochccta  pallida)  has 
been  demonstrated  in  acquired  syphilitic  pulmonary  lesions,  its 
detection  presents  many  serious  technical  difficulties.  Care  must 
be  exercised  to  avoid  mistaking  other  spirochsetje  which  may  be 
present  in  the  lung  for  the  true  Spirochccta  pallida. 

Dift'use  fibroid  induration  of  the  lung,  occurring  in  asso- 
ciation W'ith  gummata  or  independently,  is  believed  to  develop 
as  a  manifestation  of  syphilis.  The  process  may  involve  parts 
or  the  whole  of  one  lung,  being  usually  most  marked  at  the 
root.  As  so  frequently  happens  in  the  presence  of  any  fibroid 
changes  in  the  lung,  bronchiectasis  may  result  from  this  form 
of  syphilitic  disease.  Some  question  exists  as  to  whether  this 
dift'use  fibroid  induration  should  be  considered  definitely  as  a 
syphilitic  process,  the  microscopic  appearance  not  being  dis- 
tinctive. The  entire  problem  of  syphilitic  disease  of  the  lung  is 
one  w^hich  is  far  from  being  settled,  some  w^riters  believing 
that  pulmonary  lesions  which  may  be  manifested  clinically  is 


PULMONARY    SYPHILIS.  491 

a  relatively  common   disorder,  others   maintaining"  that  it  is 
extremely  rare. 

The  symptoms  of  syphilis  of  the  lung  are  in  no  way  char- 
acteristic, being  dependent  upon  the  changes  produced  in  the 
surrounding  tissues,  and  not  upon  the  lues,  per  sc.  Stenosis 
or  dilatation  of  the  bronchi  may  result,  or  possibly  a  combina- 
tion of  both  conditions,  with  all  the  manifestations  of  bron- 
chiectasis and,  possibly,  cavity  formation.  The  role  of 
syphilis  in  the  production  of  fibroid  changes  in  the  lungs, 
either  the  generalized  or  the  circumscribed  form,  has  of  recent 
years  attracted  considerable  attention,  especially  the  pos- 
sibility of  its  causing  certain  of  the  fibroid  changes  at  the 
apex.  In  patients  presenting  evidence  of  localized  fibrosis, 
even  at  the  apex  of  the  lung,  in  which  tubercle  bacilli  have 
been  absent  persistently  for  a  long  period  of  time,  it  may  be 
well  to  bear  in  mind  the  possibility  of  syphilis  as  a  causal 
factor.  So  little  is  definitely  known  of  the  various  ways  in 
which  syphilis  may  affect  the  lungs,  that  this  possibility 
should  be  considered  in  studying  any  obscure  pulmonary 
process.  While  the  symptoms  of  pulmonary  syphilis  are  not 
definite  or  distinctive,  there  are  certain  clinical  features  of 
syphilitic  disease  of  the  lungs  which  should  suggest  its  poten- 
tial bearing  in  the  questionable  case.  In  any  patient  with  a 
disease  of  the  lung  which  has  the  general  appearance  of  pul- 
monary tuberculosis,  but  in  which  tubercle  bacilli  are  per- 
sistently absent  from  the  sputum,  when  the  other  possible 
etiologic  factors  have  been  eliminated  (actinomycosis,  etc.), 
syphilis  is  to  be  suspected  as  the  cause.  Especially  is  this 
true  when  the  general  nutrition  is  comparatively  well  maintained, 
and  when  there  is  no  elevation  of  temperature,  or  when  this 
is  subnormal.  Furthermore,  the  dyspnea  is  out  of  all  propor- 
tion to  the  extent  of  the  lesion,  and  their  distribution  is 
atypical,  especially  when  located  in  the  middle  third  of  the 
lung,  with  the  apices  free.  It  has  also  been  stated  that  in 
pulmonary  syphilis  hemoptysis  is  very  rare,  and  that  fre- 
quently  a  striking  feature  in  the  early  stages  is  the  absence  of 
moisture,  as  evidenced  by  the  absence  of  rales.  The  general 
indications  just  mentioned  refer  principally  to  gummata  of  the 
lung,  but  when  the  pulmonary  process  produces  such  changes 
as  result  in  circumscribed  bronchiectasis,  pulmonary  cirrhosis, 


492         DISEASES   OF  THE  RESPlRAtORV  SYSTEM. 

or  abscess,  the  etiologic  relation  of  syphilis  is  not  so  definite. 
The  majority  of  cases  of  pulmonary  syphilis  resemble  pul- 
monary tuberculosis  or  tumor  of  the  lung.  The  use  of  the 
Wassermann  reaction  has  been  of  such  material  assistance  in 
diagnosing  the  presence  of  a  luetic  infection,  and  it  is  so 
universally  employed,  that  a  word  of  caution  may  not  be  out 
of  place. 

When  evident  disease  of  the  lung  is  present  a  positive 
Wassermann  reaction  must  not  be  taken  as  conclusive  evi- 
dence that  the  pulmonary  process  is  syphilitic.  There  is  no 
reason  why  a  syphilitic  patient  may  not  develop  tuberculosis 
or  any  other  disease  of  the  lungs.  A  positive  Wassermann 
reaction,  however,  in  a  person  sufifering  from  disease  of  the 
respiratory  tract,  in  whom  every  possible  means  of  determin- 
ing the  actual  cause  of  the  lesion  has  failed  to  furnish  any 
definite  information,  is  sufficient  evidence  upon  which  to 
apply  the  therapeutic  test.  Even  if  the  pulmonary  lesion 
should  not  be  due  to  syphilis,  anyone  suffering  from  a  disease 
of  the  lung  who  shows  a  strongly  positive  Wassermann  re- 
action should  receive  antisyphilitic  treatment,  regardless  of 
the  nature  of  pulmonary  condition. 

Cases  have  been  reported  in  which  syphilis  was  pre- 
sumably responsible  for  the  development  of  bronchopneu- 
monia and  a  progressive  destructive  process  in  the  lungs 
(syphilitic  phthisis).  These  are  extremely  rare,  and  while 
some  writers  do  not  believe  that  the  evidence  of  syphilis  as 
an  etiologic  factor  in  the  pulmonary  process  has  been  abso- 
lutely conclusive,  the  general  tendency  has  been  to  accept 
them  as  recognized  syphilitic  lesions. 

The  treatment  of  syphilis  of  the  respiratory  tract  does  not 
dififer  from  that  of  the  infection  in  general.  The  administra- 
tion alternately  of  the  protiodide  of  mercury  and  one  of  the 
salvarsan  preparations  intravenously  probably  gives  the  best 
results.  The  general  health  and  strength  of  the  patient  usu- 
ally requires  building  up,  such  measures  as  have  been  recom- 
mended for  this  purpose  in  pulmonary  tuberculosis  being  the 
most  satisfactory. 

The  results  of  treatment  vary  with  the  amount  of  destruc- 
tion of  normal  relations  resulting  from  s^^philitic  disease, 
many  of  such  processes  being  accompanied  by  changes  in  the 


PULMONARY   ACTINOMYCOSIS.  493 

surrounding  tissues,  which,  while  dependent  upon  the  pres- 
ence of  the  syphilitic  disease,  are  not  of  themselves  actually 
luetic.  The  scarring  consequent  to  the  healing  of  gummata 
may  result  in  such  changes  in  the  lungs  or  bronchi  that 
special  treatment  will  be  required,  in  addition  to  that  directed 
solely  toward  the  eradication  of  the  syphilitic  infection. 

PULMONARY    ACTINOMYCOSIS. 

Infection  of  the  lungs  with  Actinomyces  bozds  is  an  uncom- 
mon clinical  finding,  but  the  recording  of  an  increasing  num- 
ber of  cases  places  it- among  the  diseases  which  must  be 
suspected  in  any  chronic  non-tuberculous  pulmonary  affec- 
tion. The  sputum  of  such  cases  should  be  carefully  and 
repeatedly  searched  for  the  small  nodular  masses  containing 
the  club-shaped  filaments,  which  may  be  clearly  demonstrated 
by  Gram's  method  of  staining.  While  we  know  that  the 
vegetable  parasite  which  may  cause  this  disease  in  man  is 
identical  with  that  causing  a  certain  disease  in  cattle,  the 
mode  of  infection  is  far  from  being  definitely  proved.  Primary 
implication  of  the  lung  usually  is  the  form  in  which  it  is  en- 
countered, although  the  lung  may  be  infected  secondarily  by 
the  extension  of  the  disease  from  neighboring  organs. 

The  changes  in  the  lung  as  a  result  of  infection  with 
actinomyces  resemble  those  produced  by  tubercle  bacilli  in 
the  chronic  ulcerative  type  of  the  disease.  It  difters  from 
tuberculosis  in  affecting  the  lower  lobes  more  frequently  than 
the  upper,  and  in  the  fact  that  there  is  more  marked  connec- 
tive tissue  formation.  The  actinomycotic  process  is  also  more 
likely  to  invade  surrounding  structures,  such  as  the  chest 
wall,  with  the  formation  of  sinuses,  the  bronchi  are  practically 
always  implicated ;  and  it  very  rarely  affects  both  lungs.  In 
the  later  stages  of  the  disease  the  chest  wall  is  almost  always  per- 
forated, which  peculiarity  should  of  itself  indicate  the  nature 
of  the  process,  but  in  the  earlier  stages  the  symptoms  may  be 
merely  those  of  a  chronic  bronchitis  or  tumor-like  invasion  of 
the  lung.  There  are  no  symptoms  which  can  be  considered 
characteristic  of  the  early  stages,  except  possibly  the  presence 
of  the  small  granules  in  the  sputum.  These  can  be  easily 
demonstrated  by^djluting  the  sputum  with  three  or  four  vol- 


494  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

umes  of  water,  and  agitating  the  mixture,  after  which,  on 
standing,  the  characteristic  granules  tend  to  sink  to  the  bot- 
tom of  the  vessel.  The  examination  of  these  granules  under 
the  microscope  will  reveal  the  characteristic  arrangement  of 
the  clubbed  filaments  in  a  ray-form.  The  study  of  the  chest 
by  means  of  the  A'-rays  is  of  very  little  value  in  this  condition, 
except  in  that  it  may  reveal  pulmonary  consolidation  in  the 
deeper  portions  of  the  lung  in  some  cases  in  which  the  clinical 
symptoms  and  signs  have  suggested  merely  a  bronchitis. 

The  medical  treatment  is  purely  symptomatic,  being 
directed  chiefly  toward  the  relief  of  cough,  expectoration,  and 
pain.  lodid  of  potassium  has  proved  "Very  effectual  in  actino- 
mycotic disease  in  other  parts  of  the  body,  but  this  drug 
seems  of  only  moderate  value  in  the  pulmonary  form.  It 
has  been  employed  in  doses  of  1  to  3  drams  (3.8  to  11.6  Gms.) 
a  day  over  a  long  period  of  time,  with  symptomatic  relief  in 
some  instances. 

Operative  interference  seems  to  promise  more  than  medic- 
inal treatment,  and  should  be  considered  in  any  case  in  which 
the  disease  tends  to  progress  in  spite  of  treatment.  The  re- 
section of  ribs  or  the  excision  of  the  mass  is  more  likely  to  be 
followed  by  results  if  performed  early,  before  extensive  in- 
vasion of  surrounding  structures  has  occurred,  and  when 
the  lesion  is  still  circumscribed  and  localized  in  an  accessible 
portion  of  the  lung.  The  ,r-ray  may  prove  of  value  in  deter- 
mining whether  or  not  the  disease  is  disseminated,  when  con- 
sidering the  advisability  of  operating. 

PULMONARY    STREPTOTHRICOSIS. 

The  micro-organism  causing  this  condition  resembles  in 
many  ways  that  of  actinomycosis,  and  many  of  the  earlier 
cases  reported  have  been  due  to  a  confusion  of  the  two.  The 
micro-organisms  described  as  streptothrix  probably  include 
several  species  of  the  one  group,  and  are  characterized  by  the 
formation  of  slender  filaments,  either  free  or  forming  a  loose 
net-work,  which  may  occasionally  show  true  branching.  They 
are  Gram-positive,  and  after  staining  with  carbol-fuchsin  are 
resistant  to  the  action  of  acids,  retaining  their  color  to  a  vari- 
able   degree,    some    of   them    being    strongly    acid-fast.      The 


PULMONARY    NEOPLASMS.  495 

absence  of  clubbing  and  ray-like  arrangement  of  the  mycelia, 
and  the  acid-fast  qualities  serve  to  distinguish  the  strepto- 
thrix  from  actinomyces. 

The  resulting  pulmonary  and  pleural  adhesions  very 
closely  resemble  those  occurring  in  actinomycosis  and  in  cer- 
tain forms  of  pulmonary  tuberculosis,  usually  showing  an  in- 
filtration, with  very  little  breaking-  down  and  no  caseation,  the 
lesions  resembling  those  consequent  to  bronchiectasis,  bron- 
chopneumonia, induration,  abscess,  and  gangrene.  The 
pleura  is  frequently  affected,  with  the  formation  of  plastic  or 
serous  exudate,  and  empyema.  The  chest  wall  may  become 
invaded,  as  has  been  described  as  occurring  in  actinomycotic 
infection. 

The  symptoms  vary  with  the  gross  pathologic  lesions  in 
the  lungs,  resembling  those  due  to  tuberculosis,  broncho- 
pneumonia, fibroid  disease,  bronchiectasis,  abscess  or  gan- 
grene, and  the  majority  of-  cases  probably  are  mistaken  for 
chronic  pulmonary  tuberculosis,  malignant  disease,  pul- 
monary syphilis,  or  actinomycosis. 

There  is  no  specific  treatment  for  streptothricosis.  Atten- 
tion to  the  general  health,  as  suggested  for  the  treatment  of 
tuberculosis  is  advisable.  The  various  pulmonary  changes 
which  develop  should  receive  the  treatment  outlined  for  such 
conditions  under  bronchiectasis,  abscess,  gangrene,  pleurisy, 
etc.  lodid  of  potassium  and  Fowler's  solution  may  be  tried 
internally,  but  the  favorable  effects  ascribed  to  their  use  prob- 
ably have  little  foundation  in  fact. 

PULMONARY    NEOPLASMS. 

The  benign  tumors  of  the  lungs  possess  no  peculiar  clinical 
interest,  being  merely  pathologic  curiosities  as  occasional  un- 
expected findings  at  autopsy.  Malignant  tumors  of  the  lungs 
are  not  uncommon,  and  while  usually  secondary  to  a  growth 
in  some  other  part  of  the  body,  occasionally  may  be  primary. 
The  growth  may  arise  in  the  peripheral  portions  of  the  lung 
or  near  the  root,  the  physical  signs  being-  dependent  upon  the 
size  and  location  of  the  tumor  mass  or  masses.  As  the  process 
in  the  lungs  may  consist  of  solitary  nodules  which  seem  to 
bear  a  close  relation  to  the  bronchial  system,  or  a  diffuse, 


496  DISEASES    OF    THE    RESPIFL\TORY    SYSTEM. 

irregular  invasion  of  the  parenchyma  of  the  lung,  one  may 
readily  see  that  the  physical  signs  may  be  very  varied.  This 
lack  of  regularity'  in  the  physical  signs  of  pulmonary  neo- 
plasms should  direct  attention  to  the  possibility  of  malig- 
nant disease,  search  being  made  for  the  primary  focus  of  the 
process  in  some  other  part  of  the  body,  although,  as  previously 
stated,  the  pulmonary  lesion  may  be  primary. 

The  sy})iptoms  are  by  no  means  characteristic,  the  cough 
and  expectoration,  loss  of  weight  and  strength,  not  being 
peculiar  to  malignant  disease.  The  dyspnea  is  usually  severe, 
being  frequently  out  of  all  proportion  to  the  amount  of  lung 
invasion,  as  determined  by  examination,  and  in  obscure  dis- 
ease of  the  chest  the  occurrence  of  this  symptom  should  sug- 
gest malignant  disease  as  one  of  the  possibilities.  Carcinoma 
or  sarcoma  of  the  lungs  may  be  present  to  quite  a  considerable 
extent  without  any  physical  signs  on  auscultation,  the  only 
manifestation  being  dullness  on  percussion  and  diminished  ex- 
pansion of  the  affected  region;  or  localized  rales,  with  sup- 
pression of  breath-  and  voice-  sounds  ma}?-  be  present.  When 
situated  near  the  bronchi,  the  tumor  masses  may  give  rise  to 
pressure-symptoms,  such  as  stridor,  hard,  unproductive  cough, 
and  dyspnea. 

The  diagnosis  of  malignant  disease  of  the  lung  is  at- 
tended by  many  difticulties,  as  the  distribution  of  the  lesions 
and  the  form  they  may  take  are  not  characteristic.  The 
absence  of  any  etiologic  factor  which  might  be  discovered 
in  the  blood  or  sputum  adds  to  the  difficult}^  of  the  problem. 
Irregular,  localized  areas  of  dullness,  with  suppression  of 
breath-  and  voice-  sounds,  and  diminished  expansion,  might 
suggest  the  presence  of  malignant  disease  in  the  peripheral 
portions  of  the  lungs,  especially  when  occurring  in  a  patient 
past  middle  life,  who  shows  progressive  loss  of  weight,  severe 
dyspnea,  and  blood-tinged  sputum ;  in  such  cases  fever  may  or 
may  not  be  noted.  "When  the  root  of  the  lung  is  the  seat  of  a 
tumor,  in  addition  to  the  pressure-symptoms  mentioned,  there 
may  be  evidence  of  a  mediastinal  growth  from  an  extension 
of  the  pulmonary  disease.  The  presence  of  a  tumor-mass  in 
the  mediastinum  may  be  suspected  from  the  appearance  of 
symptoms  such  as  dullness  over  the  sternum,  extending  to 
either  side,  dullness  over  the  upper  dorsal  spines  posteriorly. 


ECHINOCOCCUS    DISEASE    OF    THE    LUNGS.  497 

atypical  murmurs  due  to  pressure  on  the  vessels,  irregularities 
of  the  radial  pulses,  tracheal  tug-,  pulsation  over  the  upper 
anterior  chest,  dilatation  of  the  superficial  veins,  edema  of  the 
chest  wall,  cyanosis,  and  cardiac  displacement.  The  sputum  is 
not  characteristic,  being  mucoid,  mucopurulent,  or  purulent, 
and  at  times  mixed  with  blood.  Hemoptysis  also  may  occur 
as  a  complication.  Microscopic  examination  may  show  the 
presence  of  small  tumor-masses,  although  they  are  usually  so 
decomposed  or  disintegrated  that  the  cellular  and  morphologic 
character  is  hard  to  determine.  Some  writers  lay  stress  upon 
the  diagnostic  value  of  numerous  isolated  cells  or  cell  clusters 
in  the  sputum,  and  upon  the  presence  of  refractive  spherical 
bodies  with  coarse  or  fine  fatty  granules. 

When  the  bronchi  are  invaded  a  positive  diagnosis  occa- 
sionally may  be  made  by  means  of  the  bronchoscope,  and  in 
every  case  the  x-ray  should  be  employed,  if  possible,  as  it  may 
give  information  of  considerable  value  in  many  cases ;  the 
radiographic  findings  may  be  at  times  misleading,  if  great  care 
is  not  exercised  in  interpreting  the  stereoscopic  plates. 

Malignant  disease  of  the  lung  is  not  amenable  to  treatment, 
and  the  most  that  can  be  done  is  to  alleviate  the  symptoms. 
Recourse  must  be  had  to  morphin  or  some  derivative  of 
opium,  to  render  the  patient  as  comfortable  as  possible. 
Treatment  by  the  ,f-rays  may  be  employed,  but  in  such  a  deep- 
seated  process  not  very  much  can  be  expected  from  their  use. 
With  our  present  means  of  examination,  it  is  hardly  possible 
to  detect  the  presence  of  these  processes  in  the  lung  at  a  time 
when  they  are  amenable  to  surgical  interference,  the  tendency 
for  the  growths  in  the  lung  to  be  rather  widely  disseminated 
usually  contraindicating  the  employment  of  surgical 
measures. 

ECHINOCOCCUS    DISEASE    OF    THE    LUNGS. 

This  relatively  rare  disease  in  man  represents  the  larval 
stage  in  the  life  cycle  of  the  Tenia  echinococciis,  which  inhabits 
the  intestinal  canal  of  dogs  and  other  closely  related  animals. 
The  most  common  intermediate  hosts  are  sheep,  cattle,  and 
swine,  and  the  cases  in  which  man  serves  in  this  capacity  are 
apparently  accidental  and  rare  occurrences.  The  source  of 
the  infection  in  human  beings  usually  is  dogs  which  have  been 


498  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

used  for  herding  sheep,  the  ova  from  the  feces  of  the  dog 
gaining  entrance  to  the  stomach  by  means  of  contaminated 
food  or  water,  or  by  hands  soiled  in  petting  or  caring  for  the 
animals.  The  embryo  develops  in  the  stomach,  and  may  bore 
its  way  into  different  parts  of  the  body  by  means  of  the  hook- 
lets  with  which  it  is  armed.  The  path  taken  by  the  embryo  in 
its  passage  from  the  stomach  to  the  lungs  is  not  clear,  the  fact 
remaining  that  it  may  appear  in  the  lung  as  a  primary  disease. 
The  embr}^os  gradually  develop  within  the  lung  with  the 
formation  of  a  C3'st,  with  a  thick,  usually  laminated  wall, 
within  which  is  the  germinal  layer  surrounding  the  cavity 
containing  fluid.  From  this  germinal  layer  heads  (scolices) 
develop,  further  growth  leading  to  the  formation  of  cysts 
within  the  mother-cyst. 

Alore  rarely  secondary  pulmonary  cysts,  may  develop  from 
extension  of  the  disease  in  the  lung,  or  in  some  adjacent  organ 
or  part  of  the  body.  The  rupture  of  hepatic  cysts  through 
the  diaphragm  may  cause  invasion  of  the  lung.  The  cysts 
ma}^  occur  singly  in  the  lung,  or  they  may  be  multiple,  may 
involve  one  or  both  lungs,  or  the  pulmonary  invasion  may  be 
part  of  a  fairly  general  invasion  of  different  portions  of  the 
body. 

Surrounding  the  thick  elastic  cuticle  of  the  parasites  a  con- 
nective tissue  capsule  of  varying  thickness  develops  between 
the  cyst  and  the  surrounding  lung  tissue,  in  which  chronic 
interstitial  changes  are  prone  to  occur.  Perforation  of  the 
cysts  frequently  takes  place,  with  evacuation  of  their  con- 
tents through  the  bronchi,  or,  more  rarely,  into  the  pleura, 
pericardium,  spinal  canal,  or  abdominal  cavity.  Suppuration 
may  occur  with  the  formation  of  a  closed  or  open  abscess 
cavity. 

The  cysts  may  remain  latent  in  the  lungs  for  months,  or 
even  years,  without  producing  symptoms.  The  symptoms 
which  commonly  accompany  the  disease  are  cough,  dyspnea, 
pain,  and  hemoptysis,  the  last-named  being  relatively  a  very 
frequent  symptom,  sometimes  appearing  even  early  in  the 
disease,  and  occasionally  being  severe  enough  to  cause  death. 
Physical  signs  m.ay  be  completely  absent  in  small  centrally 
located  cysts.  AA^hen  large  and  unruptured,  there  may  be 
unilateral    diminution    of    the    inspiratory    excursion    of    the 


PLEURAL    FLUIDS.  499 

chest,  with  possibly  a  localized  prominence,  sharply  defined 
circular  areas  of  dullness  or  flatness,  absent  vocal  fremitus 
and  resonance,  diminished  breath-sounds,  and  displacement  of 
the  heart,  liver,  and  spleen. 

Rupture  of  the  cyst  may  be  accompanied  by  hemoptysis 
and  evacuation  of  the  cyst  contents  through  the  bronchi,  or 
by  sudden  pain  and  a  collection  of  fluid  in  the  pleura.  The 
rupture  of  the  cysts  is  frequently  accompanied  by  an  attack 
of  urticaria,  the  occurrence  of  which  may  suggest  the  pos- 
sibility of  this  condition  being  responsible  for  the  pulmonary 
signs  and  symptoms  in  obscure  cases.  The  cyst  contents  can 
be  recognized  by  the  finding  of  small  pieces  of  the  laminated 
cuticle  or  by  the  presence  of  booklets,  in  a  fluid  containing 
considerable  sodium  chlorid  and  very  little  albumin.  Echi- 
nococcus  disease  is  one  of  the  numerous  causes  of  eosinophilia. 

The  .i'-rays  are  of  the  greatest  importance  in  the  detection 
of  this  disease,  especially  in  the  early  stages.  The  cysts  may 
be  recognized  by  their  sharply  defined,  well-rounded  shadows 
of  uniform  density.  Precipitin  and  complement  fixation  tests 
of  the  blood-serum  have  been  employed  for  the  detection  of 
echinococcus  disease. 

Treatment  of  thei  disease  is  purely  surgical,  consisting  of  the 
excision  of  'the  cyst  without  rupture.  Removal  of  the  contents  of 
the  cyst  by  thoracentesis,  either  with  or  without  the  injection  of 
such  substances  as  iodine  or  carbolic  acid,  is  attended  by  consider- 
able danger,  and  should  never  be  employed. 

Blastornycosis,  aspergillosis,  and  distomatosis  are  rare  pul- 
monary infections  in  the  United  States,  but  these  conditions 
must  be  considered  as  possibilities  in  obscure  pulmonary  con- 
ditions. Their  treatment  is  purely  symptomatic,  as  there  has 
been  no  specific  mode  of  therapy  yet  discovered.  Their  recog- 
nition depends  entirely  upon  detecting  in  the  sputum  the 
characteristic  micro-organisms  of  the  disease  in  question. 

PLEURAL    FLUIDS. 

The  fluids  arising  within  the  pleural  space  have  been  the 
subject  of  careful  study  and  investigation  for  many  years,  in 
the  hope  of  obtaining  data  of  sufficient  constancy  to  be  of 
value  in  determining  the  nature  of  the  morbid  process  respon- 


500  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

sible  for  the  effusion  in  the  individual  case.  The  problem  is  com- 
plicated by  the  fact  that  in  a  great  many  pleural  effusions  the 
process  is  not  simple,  but,  on  the  contrary,  referable  to  several 
different  conditions.  Thus,  an  exudate  may  have  added  to  it 
a  certain  amount  of  transudate,  or  a  pleurisy,  originally  purely 
tuberculous,  may  become  contaminated  with  some  secondary 
infection.  The  confusion  caused  by  the  conflicting  results 
reported  by  different  observers  in  studying  similar  conditions 
is  probably  due  to  the  fact  that  the  effusion  studied  did  not 
conform  to  any  one  distinct  type.  It  is  extremely  important 
that  the  information  obtained  by  the  study  of  any  given 
effusion  should  be  considered  only  in  its  relation  to  the  clinical 
findings  in  the  individual  case.  With  the  exception  of  a  few- 
positive  diagnostic  findings,  the  laboratory  study  of  the 
pleural  effusions  is  mainly  of  value  in  confirming  a  diagnosis, 
or  in  suggesting  certain  etiologic  possibilities. 

The  chief  object  in  such  findings  has  been  to  obtain  such 
information  of  value  in  decidingr  whether  such  a  collection  of 
fluid  is  an  exudate  or  a  transudate,  and,  if  the  former,  the 
nature  of  the, disease  responsible  for  its  accumulation.  When 
the  effusion  is  secondary,  it  is  not  uncommon  for  the  primary 
disease  to  be  so  obvious  that  the  study  of  the  fluid  is  unneces- 
sary. In  primary  pleural  effusions,  or  in  those  secondary 
effusions  in  which  the  primary  disease  is  concealed,  the  study 
of  the  fluid  may  prove  of  the  greatest  importance. 

The  gross  appearance  of  the  fluid  usually  indicates  whether 
it  is  serous,  serofibrinous,  fibrinopurulent,  purulent,  chylous, 
or  hemorrhagic.  A  microscopic  or  cultural  study  is  necessary 
to  determine  the  presence  of  bacteria  or  small  quantities  of 
pus,  blood,  chyle,  or  fibrin. 

As  a  rule,  transudates  have  a  low  specific  gravity  (1.010 
to  1.015),  with  an  amount  of  albumin  ranging  from  a  trace  to 
as  high  as  3  per.  cent.  Exudates,  on  the  .other  hand,  have  a 
specific  gravity  of  1.018,  or  higher,  and  an  albumin  content  of 
4  per  cent.,  or  greater.  The  exudates  show  a  fairly  abundant 
precipitate  when  acetic  acid  is  added  to  the  fluid,  and  usually 
show  a  tendency  to  coagulate  rapidly.  In  cases  close  to  the 
dividing-line  between  exudate  and  transudate  the  albumin 
should  be  estimated  by  some  of  the  more  delicate  methods,  as 
the  customary  Esbach's.  test  is  not  sufficiently  accurate. 


PLEURAL   FLUIDS.  501 

Cytology.  The  cellular  elements  in  the  effusion  have  been 
extensively  studied,  in  the  hope  that  their  general  character 
and  the  proportion  of  the  various  types  of  cells  present  would 
prove  of  value  in  differentiating  effusions  due  to  different  dis- 
eases. The  cells  are  obtained  from  the  sediment  of  the 
citrated,  centrifugalized  fluid,  mounted  on  a  slide,  and  stained 
by  Wright's  blood-stain.  A  differential  count  is  made  of  the 
leucocytes,  a  record  being  made  of  the  number  of  neutrophiles, 
basophiles,  lymphocytes,  and  endothelial  cells  in  the  same 
manner  as  in  a  blood-examination.  The  leucocytes  found  in 
the  effusion  not  infrequently  show  degenerative  changes  and 
pigmentation,  which  makes  the  process  of  counting  at  times 
somewhat  difficult.  Occasionally  cells  are  encountered  in 
which  it  is  hard  to  determine  whether  they  are  polymorpho- 
nuclear or  mononuclear,  and  these  atypical  forms,  are  best 
grouped  under  a  separate  heading,  such  as  "cells  of  uncertain 
type."  The  differentiation  between  lymphocytes  and  endo- 
thelial cells  also  may  be  extremely  difficult  in  a,  small  propor- 
tion of  the  cells. 

The  original  observations  on  the  leucocytic  counts  in 
pleural  effusions  resulted  in  the  statement  that  when  the  poly- 
morphonuclear cells  predominated  the  effusion  was  of  an  in- 
fectious origin,  when  the  lymphocytes  were  in  excess  it  indi- 
cated a  tuberculous  process,  and  when  the  endothelial  cells 
were  in  the  majority,  especially  if  arranged  in  sheets  or 
placques,  the  effusion  was  of  a  mechanical  type. 

While  the  various  leucocytic  formulae  may  be  of  value  as 
sug"gesting  various  causes  for  the  presence  of  fluid,  they  must 
not  be  considered  as  absolutely  diagnostic,  more  recent  obser- 
vations having  shown  that  the  leucocytic  picture  varies,  not 
only  in  different  processes,  but  also  in  various  stages  of  the 
same  process.  It  has  been  shown  that  in  the  tuberculous 
effusions  a  temporary  increase  of  the  polymorphonuclear  ele- 
ments may  be  found  in  the  early  stages,  and  that  a  secondary 
infection  may  modify  the  numerical  relation  of  the  cells.  In 
transudates  of  long  standing  the  lymphocytes  may  be  in  ex- 
cess instead  of  the  endothelial  cells,  and  an  excess  of  lympho- 
cytes occasionally  may  be  found  in  non-tuberculous  exudates. 
The  effusions  due  to  malignant  disease  usually  show  an  excess 
of  endothelial  cells.     The  polymorphonuclear  predominance 


502  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

commonly  present  in  effusions  due  to  the  pneumococcus, 
streptococcus,  or  staphylococcus  is  probably  the  most  con- 
stant of  the  various  leucocytic  formulae. 

Bacteriology.  For  the  detection  of  pneumococci  and  the 
ordinary  pyogenic  micro-organisms,  the  usual  methods  of  cul- 
tivation are  sufficiently  reliable.  The  presence  of  tubercle 
bacilli  is  not  easy  of  demonstration,  the  cultivation  of  these 
bacteria  presenting  so  many  difficulties  as  to  render  this 
method  of  iuA'estigation  practically  useless.  The  micro- 
scopic examination  or  animal  inoculation  of  the  sediment 
obtained  by  centrifugalization  of  large  quantities  of  the  fluid 
are  the  most  reliable  methods  for  the  determination  of  these 
micro-organisms. 

The  coagulation  of  the  fluid  may  interfere  seriously  with 
this  procedure,  but  usually  it  may  be  overcome  by  the  addi- 
tion of  sodium  fluoride  or  sodium  citrate  to  the  freshly  drawn 
serum,  or  by  the  digestion  of  the  coagulum  after  the  method 
of  Jousset,  Inoculation  of  animals  for  the  detection  of  the 
tubercle  bacillus  must  be  very  carefully  performed  to  be  of 
any  value,  and  it  is  of  value  only  when  the  result  is  positive, 
as  negative  findings  do  not  absolutely  exclude  the  possibility 
of  a  tuberculous  lesion. 

ACUTE    FIBRINOUS    PLEURITIS. 

The  treatment  of  acute  fibrinous  pleuritis  necessitates  a 
knowledge  of  the  underlying  causes  responsible  for  a  develop- 
ment of  this  process,  for  it  must  be  considered  as  purely  a 
secondary  process  in  every  instance,  even  if  in  certain  cases 
the  factor  responsible  for  its  presence  cannot  be  discovered. 
The  so-called  primary  cases  constitute  a  very  small  proportion 
of  the  number  encountered,  in  which  the  etiologic  factor  can- 
not be  actually  demonstrated  or  strongly  suspected.  From  a 
practical  standpoint,  then,  the  first  principle  in  the  manage- 
ment of  a  case  of  acute  fibrinous  pleuritis  consists  in  the 
relief  of  the  patient ;  the  second,  which  is  equally  important,  is 
the  employment  of  every  means  in  our  possession  to  deter- 
mine the  actual  or  probable  condition  responsible  for  the 
pleural  inflammation.  AMiile  exposure  and  alcoholism  are 
possible  causes,  by  far  the  largest  number  of  cases  are  due 


ACUTE   FIBRINOUS    PLEURITIS.  503 

to  tuberculosis,  so  that  any  patient  presenting  signs  of  tliis 
disease  without  evident  cause  being  detected  should  be  viewed 
as  a  probable  case  of  tuberculosis,  and  every  means  employed 
to  obtain  information  as  to  the  possibility  of  such  an  infection 
by  a  study  of  the  family  and  previous  history,  symptoms,  and 
physical  examination,  including  such  clinical  and  laboratory 
tests  as  may  prove  of  value.  It  must  be  borne  in  mind  that, 
while  the  majority  of  cases  are  due  to  tuberculosis  of  the  lungs 
this  is  not  necessarily  always  the  case,  for  the  pleural  inflam- 
mation may  result  from  a  general  infection  with  tuberculosis, 
or  as  a  result  of  tuberculosis  of  some  organ  in  the  body  other 
than  the  lung.  The  pleural  condition  may  precede  the  pul- 
monary, at  least  so  far  as  one  may  determine  by  the  clinical 
means  in  our  possession  at  the  present  time. 

The  processes  other  than  tuberculosis  which  may  be  ac- 
companied by  or  be  responsible  for,  the  development  of  in- 
flammation of  the  pleura,  include  all  the  general  infections  and 
bacterial  disease  of  any  part  of  the  body,  or  it  may  accompany 
the  terminal  infections  of  one  of  the  chronic,  asthenic  dis- 
eases. The  diseases  of  the  lungs,  such  as  lobar  or  broncho- 
pneumonia, abscess,  gangrene,  and  infarction,  naturally  ac- 
count for  many  of  the  cases,  although  bronchitis  and  bron- 
chiectasis also  may  bear  a  causal  relation.  Pleuritis  may 
complicate  such  conditions  as  acute  or  chronic  endocarditis, 
tonsillitis,  arthritis,  pyorrhea  alveolaris,  pericarditis,  typhoid 
fever,  urethritis,  and  pelvic  sepsis.  Trauma  also  may  rarely 
be  responsible  for  the  development  of  the  disease. 

The  pleura  at  the  seat  of  inflammation  is  dull  and  opaque, 
the  normal  glistening  appearance  being  absent,  and  the  sur- 
face coarsely  or  finely  granular  and  usually  more  or  less 
thickened.  The  color  is  grayish-white  or  reddened,  occasion- 
ally being  of  a  dark-red  color,  due  to  the  extravasation  of 
blood.  Occasionally  the  membrane  is  thickened  to  a  marked 
degree,  or  covered  with  a  thick,  shaggy,  plastic  exudate.  The 
entire  surface  of  one  lung  may  share  in  the  process,  or  only 
small  localized  patches;  a  small  amount  of  fluid  in  excess  of 
the  normal  is  almost  always  present.  Microscopically,  the 
lymph-  and  blood-  vessels  are  dilated,  the  subserous  tissue  is 
swollen  and  contains  numerous  polymorphonuclear  leuco- 
cytes, and  the  surface  shows  degeneration  and  desquamation, 


504  DISEASES    OF   THE   RESPIR-ATORY   SYSTEM. 

with  a  covering  of  fibrin  containing  serous  exudate  and  leu- 
cocytes. This  layer  of  exudate  may  undergo  fatty  changes 
and  absorption,  or  the  round  cell  infiltration  may  organize  and 
form  connective  tissue,  with  possibly  complete  adhesion  of 
the  pleural  surfaces. 

The  symptoms  may  be  modified  or  obscured  by  the  asso- 
ciated disease,  but  in  the  majority  of  instances  the  pleural 
attacks  come  on  suddenly,  with  little  or  no  premonitory  signs, 
slight  elevation  of .  temperature,  and,  rarely,  with  an  initial 
chill.  The  most  characteristic  and  constant  symptom  is  pain, 
which  is  sharp,  cutting,  or  stabbing  in  character,  or  occasion- 
ally dull  and  dragging.  The  pain  may  be  constant  or  only 
present  on  deep  breathing  or  coughing.  It  is  usually  local- 
ized to  the  anterior  axillary  region  over  the  lower  portion  of 
the  chest,  but  may  extend  posteriorly,  or  radiate  toward  the 
shoulders.  In  rare  instances  the  pain  may  be  referred  to  the 
abdominal  cavity,  thus  naturally  directing  attention  to  that 
part  rather  than  to  the  chest,  and  hence  frequently  leading  to 
a  mistake  in  diagnosis,  especially  when  the  pain  is  accom- 
panied by  tenderness  and  rigidity  of  the  abdominal  muscles. 
Rapid,  shallow  breathing  may  be  present,  from  an  uncon- 
scious effort  on  the  part  of  the  patient  to  limit  the  respiratory 
excursion,  or,  in  rare  instances,  true  dyspnea  may  occur. 
While  cough  is  usually  present  and  is  believed  to  be  actually 
pleuritic,  the  difficulty  in  excluding  the  other  possible  causes 
of  cough  is  extremely  difficult,  especially  as  the  pleurisy  is  so 
frequently  associated  with  some  other  bronchopulmonary 
disease. 

Physical  examination  shows  the  patient  in  a  position  which 
tends  to  limit  the  expansion  of  the  aft'ected  side,  the  shoulder 
being  depressed  and  the  arm  closely  held  against  the  ribs. 
The  decubitus  varies  in  different  cases,  some  lying  on  the 
affected  side,  others  on  the  unaffected.  There  may  be  mod- 
erately suppressed  breath-sounds,  and  slight  impairment 
on  percussion,  with  decreased  vocal  fremitus  over  the 
affected  area,  but  usually  these  signs  are  lacking.  The 
characteristic  sign  is  the  presence  of  a  friction-rub,  which 
sounds  like  the  creaking  of  leather,  is  synchronous  with  in- 
spiration, becoming  intensified  toward  the  end  of  the  inspira- 
tory phase,   and  is  unaffected  by   cough.     Certain  types  of 


ACUTE   FIBRINOUS    PLEURITIS.  505 

rales  may  simulate  a  friction-rub^  but  these  may  be  distin- 
guished by  their  tendency  to  disappear  or  to  become  intensi- 
fied by  cough,  by  their  being  less  regular  or  constant,  and 
unaccompanied  by  severe  pain.  The  grating,  rumbling  sound 
heard  in  many  normal  individuals  over  the  upper  half  of  the 
posterior  thoracic  region  when  the  arms  are  folded  across 
the  chest  is  due  to  crepitus  in  the  shoulder  joint.  There  is 
some  doubt  as  to  whether  the  fine  crepitation  occasionally 
heard  in  patients  sufifering  with  localized  pain  in  the  chest  is 
due  to  pleuritis  or  to  moisture  in  the  pulmonary  tissues  im- 
mediately beneath  the  pleura.  When  the  diaphragmatic  sur- 
face of  the  pleura  is  affected,  the  diagnosis  may  be  extremely 
difficult  owing  to  the  complete  absence  of  friction-sounds,  and 
to  the  fact  that  the  pain  may  be  referred  to  the  upper  chest  or 
abdomen,  depending  upon  the  portion  of  the  diaphragm  which 
is  inflamed.  Gross  changes  in  the  lungs  may  obscure  the 
signs  of  pleurisy. 

TREATMENT. 

The  treatment  consists  primarily  in  the  adoption  of  meas- 
ures to  ensure  relief  of  the  pain,  which  may  be  of  agonizing 
severity.  When  the  pain  is  not  very  severe,  local  applications 
of  heat,  and  the  administration  of  heroin  or  codein,  or  pos- 
sibly a  hypodermic  injection  of  morphin  may  give  a  certain 
amount  of  comfort,  but  there  is  nothing  which  meets  the  re- 
quirements so  well  as  strapping  the  affected  side  with  ad- 
hesive plaster,  the  zinc  oxid  preparation  being  the  best. 

The  strips  of  adhesive,  about  2  inches  (5.08  cm.),  should 
be  cut  beforehand  the  required  length,  six  strips  usually  being 
sufficient.  Preferably  the  patient  should  be  in  the  upright 
position,  with  the  shoulder  of  the  unaff'ected  side  braced 
against  an  immovable  object,  such  as  a  wall;  the  first  strip 
attached  posteriorly,  so  that  it  extends  about  2  inches  (5.08 
cm.)  beyond  the  spinous  processes  on  the  unaft'ected  side, 
just  above  the  level  of  the  lower  costal  margin.  At  the  end 
of  a  forced  expiration,  the  adhesive  strip  is  forcibly  applied 
around  the  chest,  in  a  slightly  downward  direction,  tension 
being  made  by  manual  traction  of  the  anterior  end  of  the  strip. 
As  it  is  brought  in  apposition  to  the  chest,  firm  traction  must 
be  kept  up  until  the  strap   has  completely  surrounded   the 


506  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

affected  side  of  the  chest,  with  the  end  passed  about  2  or  3 
inches  (5.08  to  7.62  cm.)  beyond  the  anterior  median  line, 
where  it  must  be  held  for  a  few  seconds  until  it  adheres  tightly 
to  the  skin.  The  second  strip  is  placed  in  the  same  manner 
just  above  the  first,  and  overlapping  about  one-third  of  its 
width.  This  is  continued  with  other  straps  until  the  chest  has 
been  covered  up  to  the  axillary  folds,  care  being  taken  to  see 


■t 


Fig.  23. — Strapping  of  the  chest  in  acute  pleuris3^ 

that  they  are  placed  smoothly  and  evenly.  In  a  woman  with 
generous  breasts  it  ma}-  be  necessar}-  to  pass  the  anterior  ends 
of  the  few-  upper  strips  forward  and  upward,  and  the  lower 
ones  slightly  downward  and  forward,  so  as  to  avoid  covering 
the  uneven  prominence  of  the  mammary  gland.  The  anterior 
and  posterior  extremities  of  the  strips  should  be  covered  with 
another  strip  of  adhesive  running  vertically  to  prevent  their 
curling  or  becoming  loose  and  slipping.  Strapping  of  the 
chest  may  seem   a  very   simple  matter  to  describe   at  such 


ACUTE    I'JBRINOUS    PLEURITIS.  507 

length,  but  it  is  absolutely  useless,  and  may  be  very  distress- 
ing to  the  patient,  if  not  performed  correctly.  It  is  extremely 
important  that  the  ends  of  the  strips  should  pass  well  beyond 
the  anterior  and  posterior  median  lines,  overlapping  2  or  3 
inches  (5.08  or  7.62  cm.)  on  the  unaffected  side,  and  consider- 
able force  is  to  be  used  in  their  application,  if  fixation  of  the 
affected  chest  is  to  be  assured. 

Care  must  be  used  in  removing  the  adhesive,  as  tnis  pro- 
cedure usually  is  accompanied  by  considerable  pain,  to  which 
patients  ordinarily  do  not  object,  if  it  is  not  unduly  pro- 
longed. Inasmuch  as  the  skin  is  partly  denuded  by  the 
process,  the  use  of  turpentine  or  ether  for  loosening  the 
plaster  is  very  objectionable.  Soaking  the  strips  over- 
night with  cottonseed  oil  or  olive  oil  will  often  facili- 
tate their  removal.  Freeing  both  extremities  of  the  strips 
first,  and  then  pulling  on  them  quickly  and  firmly,  will 
usually  be  found  more  satisfactory  than  attempting  to  loosen 
them  for  only  a  short  distance  at  a  time.  After  they  are 
removed  the  partly  denuded  skin  should  be  quickly  coated 
with  a  bland,  soothing,  heavy  ointment,  such  as  zinc  oxide, 
as  even  the  contact  with  the  air  may  be  very  painful. 

Not  only  rest  of  the  lung  is  important,  but  rest  in  bed 
should  be  insisted  upon,  the  patient  being  allowed  to  assume 
the  position  which  seems  to  give  the  greatest  amount  of  com- 
fort, although  it  is  perhaps  preferable  to  have  him  lie  on 
the  affected  side. 

Search  should  be  made  for  a  possible  source  of  infection, 
which  when  found  should  receive  appropriate  treatment.  In 
the  absence  of  any  evident  or  probable  cause,  as  stated  above, 
the  case  should  be  considered  as  probably  tuberculosis,  and  in 
the  presence  of  any  strongly  suggestive  history,  symptoms  or 
signs,  it  is  to  be  treated  as  such.  In  such  an  event  it  is  advis- 
able to  inform  the  patient  that  tuberculosis  is  in  all' likelihood 
the  cause  of  the  trouble,  and  to  warn  of  the  importance  of 
maintaining  a  rational  mode  of  life.  Any  symptoms  such  as 
loss  of  weight,  cough,  digestive  disturbances,  temperature, 
hemoptysis,  should  be  heeded,  and  a  careful  physical  exami- 
nation made  upon  the  development  of  any  sign  suggestive  of 
phthisis.  Before  such  patients  are  permitted  to  resume  their 
ordinary  occupation,  their  general  health  should  be  built  up 


508  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 


Fig.  24. — Showing  method  of  determining  the  relative  expans- 
ibility of  the  lower  portions  of  the  chest  in  patient  with  old 
left-sided  pleurisy.  A,  during  expiration;  and  B,  at  the  end  of 
inspiration.  Note  the  difference  in  distance  from  spinous  proc- 
esses of  the  right  and  left  thumbs. 


SEROFIBRINOUS    PLEURITIS. 


509 


to  a  better  state  than  before  the  attack,  even  if  sanatorium 
treatment  is  necessary  to  accomplish  the  desired  result. 

Where  the  fibrinous  exudate  has  been  extensive,  the  acute 
attack  may  be  followed  by  a  diminution  of  expansion  on  the 
affected  side,  varying  in  amount  from  so  slight  a  decrease  as 
to  be  hardly  detectable  to  the  virtual  abolition  of  respiratoiy 
movements.  When  the  restriction  is  serious,  various  meas- 
ures may  be  employed  to  increase  the  expansion  of  the  lung, 
such  as  breathing  exercises  and  forced  expiration.  Some  care 
must  be  used  in  resorting  to  breathing  exercises  absolutely  to 
exclude  the  possibility  of  any  active  pulmonary  tuberculosis, 
or  disastrous  results  may  follow,  with  possibly  rapid  extension 


Fig.  25. — Tracing  of  lower  portion  of  chest  (level  of  5th  rib) 
in  patient  with  old  left-sided  pleurisy.  Note  the  marked  difference 
between  the  size  of  the  two  sides  of  the  chest. 

of  the  pulmonary  process.  When  slight  or  moderate  restric- 
tion is  present,  it  is  much  safer  to  dispense  with  deep-breath- 
ing exercises,  and  to  warn  the  patient  of  the  dangers  attending 
their  use.  The  operative  treatment  suggested  for  the  cases 
with  dense,  firm,  organized  exudate,  such  as  decortication, 
cannot  be  recommended,  despite  the  fact  that  fibrosis  of  the 
lung  may  possibly  develop  as  a  result  of  such  pleural  changes. 


SEROFIBRINOUS    PLEURITIS. 

A  small  proportion  of  serous  pleural  effusions  appear  to  be 
primary,  that  is,  no  definite  cause  for  the  development  of  the 
effusion  can  be  determined.     The  disease  which  is  most  fre- 


510  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

quently  responsible  for  the  process  is  tuberculosis,  and  what 
was  said  in  regard  to  the  relation  between  this  disease  and 
the  fibrinous  type  of  pleurisy  is  applicable  here. 

Among  the  non-tuberculous  efifusions  the  most  frequent 
cause  is  the  pneumococcus,  although  streptococci  and  other 
micro-organisms  may  at  times  be  responsible.  Effusions  of 
this  type  are  not  an  uncommon  sequel  of  pneumonia,  in  which 
there  is  a  decided  tendency  for  them  to  become  purulent. 
Other  diseases  in  ^vhich  serous  pleural  effusions  may  occur 
are  rheumatism,  endocarditis,  typhoid  fever,  trauma,  and  in- 
fections of  various  parts  of  the  body. 

In  addition  to  the  changes  found  in  the  simple  fibrinous 
type  of  pleuritis,  there  is  a  variable  amount  of  fluid  in  the 
dependent  portion  of  the  pleural  space.  Above  the  level  of 
the  fluid  the  pleurae  may  {be  adherent,  united  by  fibrous 
bands,  or  merely  covered  with  a  small  amount  of  plastic  exu- 
date, the  two  surfaces  being  easily  separated.  The  pleura 
may  show  miliary  tubercles  on  gross  or  microscopic  examina- 
tions in  cases  in  which  the  tubercle  bacillus  is  the  etiological 
factor.  The  fluid  is  usually  pale  amber  in  color  and  may  con- 
tain fibrin  in  the  form  of  thin,  thread-like  or  irregular,  thick, 
dense  clots.  The  dividing-line  between  serofibrinous  fluids 
which  are  cloudy  from  the  admixture  of  numerous  cells  and 
those  containing  an  admixture  of  pus  is  by  no  means  definite 
and  fixed,  the  two  types  frequently  shading  into  one  another. 
The  study  of  the  pleural  fluids  is  considered  in  more  detail  in 
a  separate  section  (see  Pleural  Fluids,  p.  499). 

While  small  amounts  of  fluid  may  exist  with  a  negative 
intrapleural  pressure,  with  increasing  amounts  this  usually 
becomes  positive,  depending  upon  the  amount  of  serous 
exudate  and  the  presence  or  absence  of  pleural  adhesions  or 
pulmonary  disease.  The  lung  becomes  contracted  as  a  result 
of  the  presence  of  the  fluid  in  massive  effusions,  and  it  may 
be  compressed  into  a  small  mass  lying  against  the  vertebra 
in  the  upper  posterior  part  of  the  thoracic  cavity,  more  or  less 
completely  devoid  of  air  and  blood.  When  the  lung  is  not 
the  seat  of  marked  inflammatory  changes,  even  after  having 
been  compressed  for  a  considerable  length  of  time,  still  it  is 
capable  of  re-expansion.  This  is  not  so  likely  if  the  fluid  con- 
tains much  fibrin  or  cellular  exudate,  as  adhesions  are  more 


SEROFIBRINOUS    PLEURITIS.  511 

likely  to  form  and  prevent  re-expansion.  The  purulent  effu- 
sions are  even  less  likely  to  be  followed  by  complete  re- 
expansions. 

The  onset  of  the  disease  varies  very  much,  for  while  some 
cases  arise  suddenly,  with  all  signs  of  an  acute  illness,  in 
others  the  onset  may  be  so  insidious  as  to  pass  unnoticed  by 
the  patient,  being  detected  only  on  routine  examination.  It  is 
not  a  very  uncommon  experience  to  have  an  individual  come 
for  examination  on  account  of  slight  dyspnea  and  to  discover 
an  entirely  unsuspected  pleural  effusion,  perhaps  so  massive 
as  to  reach  nearly  to  the  level  of  the  clavicle. 

The  diagnosis  does  not,  as  a  rule,  present  any  great  diffi- 
culties in  the  average  case,  although  we  must  admit  that  it 
is  only  possible  to  recognize  effusions  clinically  after  they 
become  fairly  large.  In  the  presence  of  extensive  disease  of 
the  lung,  or  adhesions  in  the  pleural  space,  the  diagnosis  of  a 
small  effusion  may  be  difificult. 

Pain  may  be  present  in  the  early  stages,  but  it  usually 
decreases  as  the  level  of  the  fluid  rises.  A  short,  dry  cough 
in  uncomplicated  cases  is  very  common,  with  a  variable  eleva- 
tion of  temperature  and  an  increased  pulse-rate. 

The  physical  signs  vary  with  the  amount  of  fluid  present; 
when  slight,  the  appearance  of  the  patient  and  inspection  of 
the  chest  may  not  differ  from  that  described  under  Fibrinous 
Pleurisy  (q.v.).  As  the  amount  of  fluid  increases,  there  is 
more  and  more  dyspnea,  which  may  be  extremely  severe,  espe- 
cially in  the  cases  which  develop  rapidly. 

Loss  of  motion,  bulging  of  the  interspaces  on  the  affected 
side,  and  increase  in  their  width,  as  determined  by  actual 
measurement,  may  be  noted.  Litten's  shadow  phenomenon  on 
the  affected  side  is  usually  absent,  the  cardiac  apex-beat  may 
be  seen  to  be  displaced,  and  in  rare  cases  there  is  pulsation  of 
the  chest  wall  on  the  affected  side. 

Palpation,  in  addition  to  confirming  the  information  ob- 
tained by  inspection,  may  reveal  downward  displacement  of 
the  liver  or  spleen.  Tactile  fremitus  is  absent  in  practically 
every  case,  and  constitutes  a  very  valuable  diagnostic  sign 
of  fluid.  Percussion  shows  normal  resonance  (in  lungs  not 
diseased)  over  the  upper  portion  of  the  chest,  and  flatness  at 
the  base ;  between  the  two  there  is  usually  a  zone  over  which 


512 


DISEASES    OF   THE   RESPIRATORY   SYSTEM. 


the  resonance  has  a  tympanitic  quality  (Skoda's  resonance). 
In  some  cases  this  tympanitic  area  extends  to  the  apex  on  the 
affected  side.  When  the  fluid  is  of  any  considerable  amount 
the  sound  at  the  base  is  flat,  and  usually  accompanied  by  a 
distinct  sense  of  resistance  to  the  pleximeter  finger  during 
percussion.  Above  the  level  of  the  flatness  there  is  usually 
a  narrow  zone  of  dullness,  which  becomes  wider,  or  is  only 


Fig.  26. — Percussion  findings  in  right-sided  pleural  effusion. 
Note  area  of  flatness  with  triangular  zone  of  dullness  immediately 
above.  To  the  left  of  spinal  flatness  is  the  area  of  dullness  known 
as  Grocco's  triangle  (G). 

noticeable  posteriorly.  The  flatness  merges  below  with  the 
liver  dullness  when  the  fluid  occupies  the  right  pleural  sac, 
but  in  the  left-sided  effusions  gastric  tympany  may  obscure 
the  signs.  In  massive  left-sided  cases  Traube's  semilunar 
space  may  be  obliterated.  The  upper  level  of  the  flatness 
usuallv  forms  a  cur^-ed  line  around  the  chest  when  the  patient 
is  in  the  upright  position,  usually  being  highest  in  the  axillary 


SEROFIBRINOUS    PLEURITIS.  513 

region.  Pleural  adhesion  may  interfere  with  this  character- 
istic curve  of  the  upper  border  of  flatness,  and  also  with  the 
shifting  of  the  level  of  the  fluid  with  change  of  position,  which 
otherwise  is  usually  present. 

The  flatness  corresponding  to  the  level  of  the  fluid,  can 
usually  be  elicited  by  percussion  of  the  spine.  A  triangu- 
lar area  of  dullness  (Grocco's  triangle)  on  the  unaffected 
side  always  can  be  elicited  in  efifusions  which  are  not  en- 
capsulated, when  they  have  attained  a  moderate  size.  The 
vertical  side  of  the  triangle  corresponds  to  the  flatness 
obtained  by  percussing  the  spinous  process,  the  horizontal 
base  to  a  continuation  of  the  lower  level  of  pulmonary 
resonance,  the  obliquely  vertical  outer  side  of  the  triangle 
being  determined  by  percussing  the  unaffected  side  in  a 
series  of  horizontal  lines  parallel  to  the  lower  border  ofi 
pulmonary  resonance.  It  is  usually  found  to  be  a  right-sided 
triangle,  with  a  long  vertical  base  corresponding  to  the  spine, 
the  short  side  being  horizontal,  and  a  long  hypotenuse  extend- 
ing obliquely  downward  and  outward  from  the  upper  level 
of  flatness  of  the  spine  to  a  point  %  to  2%  inches  (2  to  7  cm.) 
from  the  spine  at  the  lower  level  of  pulmonary  resonance  on 
the  unaffected  side.  Occasionally  the  legs  of  the  triangle  are 
of  equal  length. 

With  displacement  of  the  heart  toward  the  unaffected 
side,  percussion  may  be  employed  to  confirm  the  findings 
as  determined  by  inspection  and  palpation,  also  the  down- 
ward displacement  of  the  liver  or.  spleen  depending  on  the 
side  affected.  Auscultation  may  reveal  the  presence  of  a 
friction-rub  above  the  level  of  the  fluid,  especially  in  the 
early  stages  when  the  fluid  is  slight  in  amount.  The  breath- 
sounds  over  the  upper  portion  of  the  lung  may  be  vesicular, 
suppressed,  or  indefinite,  becoming  more  broncho-vesicular  in 
character  as  the  compression  of  the  lung  increases,  or  they 
may  be  inaudible  in  massive  effusions.  Just  above  the  level 
of  flatness  the  breath-sounds  are  frequently  broncho-vesicular 
in  character,  especially  posteriorly,  with  increased  vocal 
resonance,  which  may  be  bleating  in  character  (egophony), 
and  fine,  moist  or  crepitant  rales.  The  area  over  which  these 
signs  are  present  corresponds  to  the  area  of  dullness  above 
the  level  of  flatness,  being  usually  confined  to  the  posterior 

33 


514  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

thoracic  region.  Over  the  flat  portion  of  the  chest  the  breath- 
and  voice-  sounds  are  absent.  Cases  are  occasionally  en- 
countered in  which  bronchial  breathing  can  be  heard  over  a 
pleural  effusion,  but  the  cause  of  this  paradox  has  never  been 
satisfactorilv  explained.  The  transmission  of  the  whispered 
voice  through  an  effusion  (Bacelli's  sign),  has  been  claimed  to 
indicate  a  serous  rather  than  a  purulent  effusion,  but  this 
peculiarity  is  too  unreliable  and  uncertain  to  be  of  any  clinical 
value. 

The  employment  of  radiographs  for  studying  the  cases  in 
which  fluid  is  suspected  freqently  is  of  considerable  value  in 
confirming  the  results  of  physical  examination,  especially  in 
those  cases  characterized  by  loculation  of  the  fluid  or  by 
obscure  physical  signs.  Fluoroscopic  examination  is  not  so 
satisfactory  as  the  use  of  plates,  except  in  a  study  of  the 
diaphragmatic  excursion.  The  cardiac  and  diaphragmatic  dis- 
placements and  the  exact  extent  of  the  effusion  may  be 
definitely  determined  by  this  means  of  study,  and  the  presence 
of  pulmonary  disease  suggested. 

The  diagnosis  of  intrapleural  fluid  may  be  absolutely  con- 
firmed, and  considerable  valuable  information  obtained,  espe- 
cially in  regard  to  the  actual  cause  of  the  disease  and  char- 
acter of  the  fluid,  by  means  of  exploratory  puncture.  This 
may  be  made  painless  by  the  injection  of  a  small  quantit}^  of 
novocaine  and  adrenalin  solution,  which  is  placed  in  the 
syringe  and  injected  verj^  slowly.  In  addition  to  obtaining 
sufficient  fluid  for  stud}^,  the  resistance  met  with  by  the  needle 
frequently  indicates  any  thickening  of  the  pleura,  or  increase 
in  its  density.  Rarely  small  plugs  of  tissue  are  caught  in  the 
lumen  of  the  needle,  and  may  be  studied  microscopically,  the 
information  thus  obtained  in  very  rare  instances  being  suffi- 
cient for  an  absolute  diagnosis  as  to  the  nature  of  the  pleural 
process. 

Having  determined  the  existence  of  fluid  in  the  pleural 
space,  there  are  several  points  in  regard  to  which  it  is  neces- 
sary to  have  additional  information  before  one  may  outline 
the  proper  course  of  treatment. 

In  the  first  place,  it  is  necessary  to  determine  whether  one 
is  dealing  with  a  pleural  exudate  or  with  a  transudate,  or, 
in  other  words,  with  a  true  inflammatory  process  of  the  pleura 


SEROFIBRINOUS    PLEURITIS.  515 

or  an  osmotic  transudation  due  to  hydremia  or  stasis  second- 
ary to  cardiac  or  renal  disease.  The  presence  of  any  disease 
of  the  heart  or  kidney  should  suggest  the  probability  of  a 
hydrothorax,  or  the  general  course  and  symptoms  may  sug- 
gest a  pleuritis,  but  a  physical  study  of  the  fluid  is  necessary 
to  distinguish  definitely  between  these  two  conditions. 

The  question  of  tuberculosis  as  a  cause  of  the  exudate  also 
is  extremely  important,  just  as  in  the  fibrinous  form  of  pleurisy, 
only  here  we  have  the  additional  advantage  of  the  data  to  be 
derived  from  a  study  of  the  fluid.  A  study  of  the  cellular  ele- 
ments of  the  fluid  may  be  of  some  help,  although  such  findings 
are  not  to  be  absolutely  depended  upon.  Examination  of  the 
sediment  obtained  by  Centrifugalization,  digesting  the  fibrin- 
ous clots  for  the  presence  of  tubercle  bacilli,  and  the  use  of 
animal  inoculations  are  absolutely  conclusive,  when  the  results 
are  positive.  Unfortunately,  when  the  presence  of  tubercle 
bacilli  cannot  be  demonstrated  it  is  not  possible  to  exclude 
tuberculosis  as  a  possible  cause  of  the  process  (see  Pleural 
Fluids).  Where  no  obvious  cause  for  the  development  of  the 
effusion  can  be  detected,  it  would  seem  the  wisest  plan  to 
consider  it  as  tuberculous,  unless  proven  to  the  contrary. 

TREATMENT. 

The  general  treatment  of  the  secondary  pleurisies  must  to 
a  great  extent  be  governed  by  the  nature  of  the  process  re- 
sponsible for  the  effusion.  Where  the  primary  disease  is 
not  discoverable,  the  patient  should  be  treated  as  if  suffering 
from  tuberculosis,  especially  as  three  or  four  out  of  every  ten 
cases  of  this  type  of  effusion  are  likely  to  manifest  active  pul- 
monary tuberculosis  within  a  few  years.  The  patient  should 
be  warned  of  the  danger  which  may  result  from  neglected 
attacks  of  cough,  temperature,  or  other  evidence  of  disease 
which  may  indicate  beginning  pulmonary  tuberculosis,  and 
impressed  with  the  importance  of  maintaining  his  health  at 
the  highest  possible  level,  and  of  not  neglecting-  the  develop- 
ment of  any  unfavorable  symptom.  These  patients  should 
receive  the  same  careful  attention  as  one  would  give  a  frank 
case  of  phthisis,  being  advised  of  the  importance  of  fresh  air, 
rest,  nutritious  diet,  and  regulated  exercise.     (See  p.  412.) 


516  DISEASES    OF    THE   RESPIRATORY    SYSTEM. 

The  treatment  should  be  directed  toward  encouraging  the 
absorption  of  the  fluid  by  increasing  the  elimination  of  fluids 
from  the  body  through  the  skin,  kidneys,  and  intestines. 
While  this  method  is  generally  recommended,  it  must  be 
acknowledged  that  it  is  questionable  whether  any  impression 
can  be  made  upon  a  pleural  effusion  by  increasing  the  excre- 
tion of  water  from  the  body,  even  when  employed  in  combina- 
tion with  a  dry  diet.  Small  doses  of  potassium  iodid,  or 
syrup  of  the  iodid  of  iron  have  been  recommended  as  of  value 
in  hastening  the  absorption  of  pleural  effusions  of  long  stand- 
ing. The  salicylates  in  doses  of  1  dram  (3.8  Gms.)  to  2  drams 
{7 .7  Gms.)  in  the  twenty-four  hours  are  claimed  to  be  of  con- 
siderable benefit  in  the  early  stages  of  pleuritis. 

Local  applications  of  heat,  and  in  some  cases  an  ice-bag,  is 
useful  to  relieve  the  pain  and  distress,  and  blisters  applied  to 
the  chest  at  times  appear  to  assist  in  the  absorption  of  the 
effusion.  The  prepared  cantharides  plaster  is  the  most  con- 
venient method  for  blistering  the  skin,  a  piece  of  the  plaster 
2  or  3  inches  (5.08  or  7.62  cm.)  square  being  applied  to  the 
skin,  after  carefully  cleansing,  at  a  point  corresponding  to  the 
level  of  the  fluid.  The  plaster  should  remain  in  contact  with 
the  skin  until  a  blister  has  formed,  or  a  marked  hyperemia 
has  developed.  Should  a  blister  fail  to  develop,  the  plaster 
may  be  removed  and  cloths  wrung  out  in  hot  water  applied, 
and  changed  at  frequent  intervals.  By  choice,  the  blister  is 
allowed  to  remain  unbroken,  being  merely  covered  with  a 
loose  gauze  dressing  and  a  bit  of  cotton,  or  the  skin  may  be 
broken  and  boracic  acid  ointment  applied  to  the  surface. 

The  measure  which  is  by  far  the  most  satisfactory  for  the 
removal  of  an  effusion  is  aspiration.  This  procedure,  when 
carefully  performed  is  very  seldom  accompanied  by  any  dan- 
ger, at  least  with  none  which  cannot  be  guarded  against  by 
the  exercise  of  care  and  judgment.  When  an  effusion  into 
the  pleural  cavity  is  detected,  the  question  arises  as  to  when 
to  aspirate,  the  quantity  to  remove  at  the  operation,  and 
whether  any  contraindications  to  this  method  of  treatment  are 
present. 

Thoracentesis  should  be  immediately  resorted  to  if  pres- 
sure-symptoms are  present,  such  as  evidence  of  rapidly  de- 
veloping cardiac  failure,   with   rapid  pulse   and   cyanosis,   or 


SEROFIBRINOUS    PLEURITIS.  517 

severe  dyspnea,  sufficient  fluid  being-  removed  to  alleviate  the 
dangerous  symptoms.  If  the  effusion  is  massive,  and  has 
produced  marked  displacement  of  the  viscera  from  their  nor- 
mal, positions,  the  withdrawal  of  the  fluid  should  not  be  de- 
layed, even  if  pressure-symptoms  are  not  present.  Even  when 
there  is  only  a  moderate  amount  of  fluid  which  has  shown  no 
tendency  to  become  absorbed  under  active  general  and  local 
treatment,  the  advisability  of  removing  some  of  it  must  be 
considered,  as  a  slight  reduction  in  the  amount  of  the  effusion 
may  be  sufficient  to  allow  the  remainder  of  the  fluid  to  be 
absorbed. 

In  the  face  of  an  actual  or  suspected  active  pulmonary 
tuberculosis  great  caution  must  be  exercised  in  the  with- 
drawal of  the  fluid  (as  described  under  Tuberculosis).  Re- 
moval by  aspiration  is  sufficient  when  the  fluid  is  clear,  but 
when  cloudy  and  suggestive  of  pus,  it  may  be  necessary  to 
consider  the  advisability  of  an  open  operation,  with  the 
establishment  of  permanent  drainage.  The  general  symptoms 
of  the  patient,  the  factor  responsible  for  the  effusion,  the  con- 
dition of  the  lungs,  and  the  character  of  the  fluid  all  have  to 
be  considered  in  deciding  upon  whether  it  is  necessary  to 
resort  to  thoracotomy  or  not.  While  thoracentesis  alone  may 
cure  a  certain  number  of  purulent  effusions,  it  cannot  be 
counted  upon  invariably  to  do  so,  and  the  dangers  which 
attend  delay  in  promptly  draining  pus  in  the  pleura  are  so 
great  that  the  open  operation  should  be  performed  as  early  as 
possible  in  every  case  of  empyema.  When,  the  ffuid  is  merely 
cloudy,  of  moderate  amount,  and  the  patient  non-toxic,  simple 
aspiration  may  be  tried,  with  the  understanding  that  the  more 
radical  operation  be  performed  on  the  first  appearance  of  any 
unfavorable  symptom  or  change  in  the  character  of  the  fluid. 

Thoracentesis.  The  use  of  a  trocar  connected  with  a  two-way 
outlet  is  much  to  be  preferred  to  the  use  of  a  needle.  The 
fittings  should  be  absolutely  air-tight,  so  as  to  prevent  the 
possibility  of  air  gaining  admission  to  the  pleural  space. 
After  entering  the  pleural  space  the  fluid  may  be  removed 
by  siphonage  or  by  aspiration,  the  latter  being  by  far  the  most 
satisfactory.  When  about  to  perform  this  operation  a  great 
deal  of  annoyance  and  chagrin  may  be  avoided  by  first  test- 
ing out  the  apparatus,  in  order  to  see  that  the  instrument  is 


518  DISEASES    OF    THE    RESPIJL^TORY    SYSTEM. 

complete,  patulous,  air-tight,  and  in  perfect  working  order. 
The  connections  of  the  trocar,  cannula,  stylet,  and  stop-cock 
should  be  gone  over  carefully,  and  it  is  always  advisable  to 
see  that  the  pump  for  exhausting  the  vacuum  bottle  has  a 
tight-fitting  plunger. 

The  skin  having  been  scrubbed  with  soap  and  water,  and 
sterilized  with  iodin,  local  anesthesia  is  induced  by  the  hypo- 
dermic injections  of  a  4  per  cent,  solution  of  novocain,  either 
with  or  without  the  preliminary  use  of  an  ethyl  chlorid  spray. 
The  entire  outfit,  with  the  exception  of  the  pump,  should  be 
sterilized  by  boiling;  the  glass  bottle  used  to  receive  the 
aspirated  fluid  also  should  be  sterilized,  if  a  bacteriologic 
study  of  the  fluid  is  intended. 

The  trocar  is  inserted  in  the  interspace  selected,  and 
its  point  kept  close  to  the  upper  edge  of  the  rib,  in 
order  to  avoid  the  intercostal  vessels.  Widening  of  the 
interspace  may  be  secured  by  shifting  the  position  of  the 
body.  The  erect  position  in  bed  is  the  best,  with  the  sub- 
ject reclining  upon  a  firm  cushion  upon  the  unaffected  side, 
and  the  arm  placed  across  the  chest  with  the  hand  resting 
upon  the  corresponding  shoulder.  The  fourth  or  fifth  inter- 
space in  the  mid-axillary  line  is  the  most  convenient  and 
satisfactory  point  at  which  to  insert  the  trocar  when  the 
effusion  is  large ;  when  small,  the  seventh  interspace  in  the 
post-axillary  region  is  better.  The  instrument  is  grasped 
firmly  in  the  right  hand,  with  the  end  resting  against  the 
palm  of  the  hand,  and  the  index  finger  pressed  against  the 
trocar  about  Ij^  inches  (3.81  cm.)  from  the  point,  so  as  to 
prevent  too  deep  insertion.  The  trocar  is  thrust  steadily  and 
firmly  into  the  pleural  space,  hugging  the  upper  border  of  the 
rib,  a  sudden  loss  of  resistance  indicating  when  its  point  enters 
the  effusion.  The  stop-cock  on  the  lateral  opening  of  the 
instrument  is  kept  closed  until  the  stylet  has  been  withdrawn 
to  its  limits,  and  the  stop-cock  on  the  straight  bar  turned  off. 
The  cock  leading  to  the  rubber  tubing,  which  should  have  a 
small  section  of  glass  tube  inserted  in  its  length  near  the 
instrument,  is  then  turned  on,  and  the  fluid  allowed  to  run 
slowly  into  the  bottle,  from  which  the  air  has  been  exhausted 
by  means  of  the  hand-pump.  It  is  a  mistake  to  make  the 
negative  pressure  in  the  bottle  too  high,  as  very  little  is  sufifi- 


SEROi'lBRlNOUS    I'LEURITIS.  519 

cient  to  withdraw  the  fluid  when  the  cannula  is  in  the  pleural 
space  and  not  occluded  by  fibrin.  The  instrument  should  be 
held  firmly  in  position,  and  a  lookout  kept  for  any  sensation 
indicating  that  the  opening  had  been  suddenly  occluded  by  a 
particle  of  fibrin,  or  that  the  lung  was  in  contact  with  the  can- 
nula. In  either  event  the  obstruction  may  be  removed  by 
means  of  the  stylet,  or  the  position  of  the  cannula  shifted  by 
withdrawal  or  lowering  of  the  point. 

When  sufficient  fluid  has  been  obtained  the  stop-cocks 
should  be  turned  off,  a  piece  of  gauze  held  around  the  trocar 
tightly  against  the  opening  in  the  skin,  and  the  instrument 
quickly  withdrawn.  The  opening  in  the  skin  should  be  sealed, 
and  while  occasionally  a  small  amount  of  oozing  may  occur, 
this  can  be  avoided  by  slightly  displacing  the  skin  upward  on 
inserting  the  trocar  so  that  when  complete  the  opening  in  the 
muscular  tissue  is  not  in  direct  apposition  to  the  opening  in 
the  skin.  A  small  collodion  and  gauze  dressing  is  usually 
sufficient,  but  a  large  dry-gauze  dressing  may  be  applied  over 
the  small  dressing,  and  held  in  position  with  adhesive  plaster 
if  any  oozing  occurs. 

During  the  withdrawal  of  the  fluid  the  operation  should  be 
discontinued  if  severe  cough,  severe  pain,  symptoms  of  shock, 
hemoptysis,  or  dyspnea  develop.  Not  infrequently  the  opera- 
tion is  accompanied  by  a  slight  sense  of  faintness  or  vertigo, 
usually  relieved  by  having  the  patient  lie  flat  in  bed  for  a  few 
minutes,  when  the  paracentesis  may  usually  be  continued.  At 
times  some  difficulty  may  be  experienced  in  inserting  the 
trocar  on  account  of  the  narrowness  of  the  interspaces  be- 
cause of  the  patient's  unconscious  resistance  to  the  introduc- 
tion of  the  trocar  by  fixation  of  the  chest  and  inclining  the 
shoulders  downward  toward  the  affected  side.  It  must  be 
remembered  that  the  chest  wall  varies  in  thickness,  and  while 
the  average  is  from  %  to  1%  inches  (2  to  4  cm.),  in  very  stout 
people  it  may  be  necessary  to  insert  the  trocar  to  a  greater 
depth  before  the  fluid  is  reached.  In  some  cases,  especially 
those  of  long  standing,  there  may  be  a  considerable  thickening 
of  the  pleura,  usually  recognized  by  the  sense  of  resistance  to 
the  needle.  The  fluid  should  be  removed  slowly,  and  with 
advantage  the  aspiration  may  be  suspended  for  a  few  minutes 
intermittently,  for  if  aspirated  too  fast  unfavorable  symptoms 


520 


DISEASES    OF    THE    RESPIIL^TORY    SYSTEM. 


may  develop,  and  occasionally  prove  serious.  From  fifteen  to 
twent}^  minutes  should  be  allowed  for  every  34  ounces  (1000 
mils)  of  fluid  withdrawn,  the  amount  to  be  aspirated  varying 
in  different  cases,  but  never  exceeding  68  ounces  (2000  mils). 
It  is  not  necessary  to  evacuate  small  efifusions  completely  as 
the  small  amount  of  serum  left  in  the  pleural  space  usually  is 
readily  absorbed.  AA^hen  the  efTusion  is  massive,  it  is  better 
to  complete  the  removal  of  the  fluid  at  a  subsequent  operation 
than  to  remove  a  very  large  amount  at  one  sitting. 


Fig.  27. — Apparatus  (Potain)  for  performing  thoracentesis. 
Instead  of  the  straight  needle  shown  in  the  illustration,  a  needle 
fitted  wtth  stjdet  niaj^  be  emploj^ed. 


The  danger  of  infecting  the  pleura  is  insignificant,  if  care 
is  exercised  in  preparing  the  patient  and  the  instruments,  and 
in  performing  the  operation.  Attention  to  the  fittings  of  the 
aspirator,  and  preventing  an}^  injury  to  the  lung,  will  avoid 
the  possibility  of  pneumothorax.  AVith  some  instruments  air 
may  be  pumped  into  the  glass  container,  instead  of  withdrawn, 
if  the  wrong  nozzle  of  the  pump  is  attached  to  the  rubber 
tubing,  and  it  is  well  to  see  to  this  point  personally,  and  not 
depend  upon  an  inexperienced  assistant  to  manage  the  pump. 
Potain's  model  is  probably  the  most  satisfactory  aspirator  now 
available  (Fig.  27^. 


PURULENT    PLEURITIS.  ^21 

Subcutaneous  emphysema  occasionally  develops  locally  or 
generally,  but  as  a  rule,  it  is  not  of  a  serious  nature.  Pul- 
monary edema  and  albuminous  expectoration  rarely  occur, 
usually  as  a  result  of  the  sudden  withdrawal  of  a  large  amount 
of  fluid.  Sudden  death  from  the  operation  has  occurred,  in 
consequence  of  shock,  embolism,  or  hemoptysis,  but  this  acci- 
dent is  exceedingly  rare.  Care  must  be  exercised  in  some 
cases  to  avoid  wounding  the  heart  or  diaphragm,  when  the 
thoracic  viscera  have  been  forced  to  assume  abnormal  posi- 
tions by  pressure  or  by  contraction  induced  by  disease  within 
the  chest. 

The  after-care  of  subjects  of  pleural  effusion  includes  such 
measures  as  may  be  necessary  to  meet  the  indications.  The 
building  up  of  the  general  health,  especially  when  tuberculosis 
is  suspected,  and  the  restoration  of  a  normal  pulmonary  ex- 
pansion in  effusions  obviously  not  due  to  tuberculosis,  will  in 
the  average  case  be  the  main  objects  of  the  treatment  after 
the  fluid  has  disappeared  from  the  pleural  space. 

PURULENT    PLEURITIS. 

The  purulent  form  of  pleural  effusion,  or  empyema,  is 
rarely  a  primary  process,  being  usually  secondary  to  some 
disease  of  the  lung,  pneumonia  being  by  far  the  most  common 
cause ;  less  frequently,  tuberculosis  or  gangrene  is  the  primary 
factor.  The  process  may  extend  from  a  neighboring  organ  to 
the  pleura,  arise  in  the  course  of  some  infectious  disease,  or 
occur  as  a  complication  of  suppuration  in  some  other  part  of 
the  body.  Serofibrinous  pleurisy  may  become  purulent  as  a 
result  of  the  primary  bacterial  invasion,  or  after  a  later  bac- 
terial infection  in  an  effusion  previously  sterile.  It  is  more 
common  in  children,  in  whom  the  serofibrinous  form  is  rela- 
tively infrequent,  X^e  pneumococcus,  streptococcus,  staphy- 
lococcus, and  tubercle  bacillus  are  the  micro-organisms  usu- 
ally responsible  for  this  condition,  the  first-mentioned  being  by 
far  the  most  frequent  cause  ("metapneumonic  empyema"), 
the  other  bacteria  named  but  seldom  having-  a  direct  etiologic 
relation. 

In  this  type  of  pleuritis  the  pleura  is  usually  thickened,  of 
a  grayish  or  yellowish  color,  and  covered  with  a  rough  or 


522  DISEASES    OF   THE   RESPIRATORY    SYSTEM. 

shaggy  fibrinous  or  purulent  exudate.  The  entire  pleural  sur- 
face of  one  lung  may  be  affected,  or  the  pathologic  process 
may  be  confined  to  the  lower  portion,  or  the  collection  of  pus 
may  be  walled  off  from  the  general  pleural  space  forming 
what  is  known  as  lociilated  empyema.  Areas  of  ulceration  and 
breaking  "down  of  the  parietal  or  visceral  pleura  may  be  pres- 
ent. The  changes  in  the  other  organs  as  the  result  of  the  dis- 
ease responsible  for  the  formation  of  an  empyema  can  usually 
be  demonstrated.  The  lung  is  most  frequently  the  seat  of 
disease,  as  the  large  majority  of  empyemata  develop  as  the 
result  of  some  pathologic  process  in  this  organ. 

The  physical  signs  and  symptoms  are  practically  the  same 
as  in  the  serofibrinous  type,  except  that  in  empyema  the  onset 
is  usually  more  acute,  and  more  commonly  associated  with 
chills,  sweats,  higher  fever,  and  a  higher  pulse-  and  respira- 
tory- rate.  The  signs  of  general  toxemia  are  usually  out  of 
all  proportion  to  the  amount  of  fluid  present.  While  usually 
rapid  in  development,  and  tending  to  become  progressively 
worse,  in  rare  instances  even  massive  collections  of  pus  may 
become  encysted,  with  a  disappearance  of  all  evidences  of 
marked  toxemia,  the  purulent  material  occasionally  becoming 
sterile,  with  the  patient  presenting  merely  such  symptoms  as 
would  indicate  compression  of  the  lung.  These  sterile  col- 
lections of  pus  may  persist  in  the  pleural  space  for  months 
or  even  years,  one  such  case  having  occurred  in  the  experience 
of  the  writer  which  had  apparently  resulted  from  a  pneumonia 
following  an  operation  for  some  pelvic  suppurative  condition 
five  years  previously. 

The  physical  signs  are  identical  with  those  found  in  effu- 
sions of  a  serofibrinous  character.  The  displacement  of  the 
heart,  liver,  and  spleen  is  perhaps  more  marked  in  purulent 
effusion's,  as  also  is  the  bulging  of  the  interspaces.  Edema  of 
the  chest  wall  is  more  frequent  in  purulent  than  in  serofibrin- 
ous effusions.  When  the  empyema  is  of  long  standing,  club- 
bing of  the  fingers  may  be  very  marked,  and  even  in  relatively 
acute  cases  changes  in  the  finger-nails  may  be  observed. 
Bacelli's  signs  for  differentiating  the  two  types  by  means  of 
the  transmission  of  the  whispered  voice  is  too  uncertain  to  be 
depended  upon  (z'.s.).  In  certain  cases,  especially  in  children, 
over  a  purulent  effusion  bronchial  breathing  may  be  distinctly 


PURULENT   PLEURITIS.  "  S23 

heard.  Pulsation  is  more  frequently  encountered  in  the  puru- 
lent than  in  serous  effusions,  although  even  the  latter  is  a 
rare  phenomenon. 

If  not  interfered  with,  collections  of  pus  in  the  pleural 
space  may  become  encysted,  as  previously  mentioned,  or  may 
rupture  into  the  lung  with  the  evacuation  of  varying  amounts 
of  pus  through  the  bronchi.  The  expectoration  of  purulent 
material  may  continue  over  a  long  period  of  time  without  the 
pleura  being  suspected  as  the  source  of  the  supply.  This  is 
more  likely  to  be  the  case  when  the  empyema  is  loculated,  and 
not  very  large.  In  certain  cases,  with  abscesses  near  the  sur- 
face of  the  lung,  it  may  be  impossible  at  autopsy  to  determine 
whether  one  is  dealing  with  an  abscess  which  has  ruptured 
into  the  pleura,  or  with  an  empyema  which  has  perforated 
the  lung. 

More  rarely,  the  purulent  collection  may  burrow  through 
the  chest  wall  with  the  formation  of  a  fluctuating  abscess  be- 
neath the  skin,  in  the  event  of  which  thoracic  aneurism  must 
be  differentiated.  The  lower  anterior  surface  of  the  chest  is 
the  region  where  these  perforations  occur,  as  the  chest  wall  is 
thinnest  in  this  area.  Cough  or  forced  expiration  usually  pro- 
duce an  increased  tension  in  the  abscesses,  which  is  percep- 
tible on  palpation,  and  occasionally  on  inspection.  The  ab- 
scess eventually  may  perforate  the  skin,  leaving  a  discharging 
sinus.  The  perforation  of  the  diaphragm  may  lead  to  the 
development  of  a  grave  form  of  peritonitis,  this  complication 
being  of  a  less  favorable  prognosis  than  the  two  previously 
mentioned.  Perforation  of  the  stomach,  intestines,  esophagus, 
or  kidney  by  collections  of  pleural  pus  also  have  been  reported. 
Septic  thrombosis  resulting  from  empyema  may  give  rise  to 
collections  of  pus  in  other  parts  of  the  body,  by  the  forma- 
tion of  purulent  emboli  and  infarcts. 

After  recovery  from  empyema  there  is  almost  invariably- 
diminished  expansion  on  the  affected  side,  and  this  defect 
usually  persists  for  some  time,  or  becomes  permanent.  The 
compression  of  the  lung  and  thickening  of  the  pleura  so  fre- 
quently resulting  from  purulent  effusions  require  a  consider- 
able time  to  reach  a  condition  which  is  even  approximately 
normal.  This  is  shown,  not  only  by  the  diminished  expansion, 
but  by  flatness  at  the  base ;  over  the  lower,  duller  portion  the 


524  DISEASES'  OF   THE   RESPIRATORY   SYSTEM. 

breath-  and  voice-  sounds  are  absent,  and  immediately  above 
it  lies  a  zone  of  bronchial  breathing  affording  numerous  fine 
moist  rales.  In  time  the  lung  tends  to  re-expand  and  the  evi- 
dences of  thickened  pleura  to  disappear,  change  being. more 
likely  in  the  cases  w^hich  have  developed  rapidly  and  have 
been  operated  upon  early.  The  empyemata  which  have  been 
allowed  to  persist  for  some  time  before  being  drained  usually 
are  accompanied  by  such  an  extensive  connective  tissue- 
formation  in  the  pleura,  and  even  in  the  lung,  that  complete 
re-expansion  never  takes  place,  and  frequently  is  followed  by 
contraction  of  the  chest  on  the  affected  side  and  even  by  de- 
formity of  the  spine. 

TREATMENT. 

The  dividing-line  between  serofibrinous  and  purulent  effu- 
sions cannot  always  be  closely  drawn,  even  when  exploratory 
puncture  has  been  made,  and  the  fluid  itself  studied.  The 
general  symptoms  and  conditions  of  the  patient,  the  presence 
of  a  rational  cause  for  the  effusion,  and  the  amount  of  fluid 
present  will  all  have  to  be  considered  in  deciding  upon  the 
treatment  to  be  instituted.  When  the  fluid  is  distinctly 
cloudy,  and  yet  not  of  a  decided  purulent  appearance,  if  a 
study  of  the  cellular  elements  and  bacteria  present  has  not 
given  evidence  of  sufficient  weight  to  guide  the  further  treat- 
ment, it  may  be  sufficient  to  aspirate,  with  the  understanding 
that  an  operation  may  be  necessary  upon  the  appearance  of 
any  reaccumulation,  or  if  the  patient's  general  condition  fails 
to  improve.  When  the  fluid  is  evidently  pus,  operative  inter- 
ference should  be  insisted  upon  at  once,  for  the  evacuation  of 
pus  before  the  formation  of  a  dense  inflammatory  exudate 
insures  a  better  coaptation  of  the  pleural  surface,  and  may 
avoid  the  possibility  of  a  long-continued,  discharging  sinus. 
The  extension  of  the  collection  of  pus  into  the  lung,  pericar- 
dium, through  the  chest  wall  or  diaphragm,  or  the  develop- 
ment of  a  general  septicemia  are  dangers  which  also  may  be 
avoided  by  early  operation. 

While  there  are  no  physical  signs  which  can  be  depended 
upon  for  determination  of  the  presence  of  pus,  there  are  cer- 
tain findings  suggesting  that  the  pleural  effusion  is  purulent 
and   not   serofibrinous;   thus    an   acute   onset   with    suddenly 


PURULENT    PLEURITIS.  525 

developing  symptoms,  edema  of  the  chest  wall,  high  tempera- 
ture, and  evidence  of  toxemia,  call  for  "an  immediate  explora- 
tory puncture.  Hyperleucocytosis  also  suggests  the  prob- 
ability of  pus,  although  practically  this  laboratory  finding 
seldom  is  of  value  on  account  of  other  coincident  pathologic 
conditions  capable  of  causing  identical  blood-changes. 

Exploratory  puncture  should  always  be  performed  with 
care,  especially  in  cases  of  long  standing,  or  when  the  em- 
pyema results  from,  or  is  a  complication  of,  pulmonary  ab- 
scess, bronchiectasis,  gangrene,  interstitial  pneumonia,  or  sup- 
purative conditions  in  the  lung.  Perforation  of  the  diaphragm, 
hemorrhage  resulting  from  perforation  of  a  blood-vessel  in 
the  walls  of  a  pulmonary  cavity,  or  bleeding  from  granulation 
tissue  may  lead  to  serious,  if  not  fatal,  results.  The  deter- 
mination of  the  position  of  the  diaphragm  should  be  pre- 
viously decided  by  means  of  a  fluoroscopic  examination  in 
any  case  in  which  its  location  is  doubtful. 

The  cases  in  which  the  greatest  care  is  demanded  are 
naturally  those  in  which  the  collection  of  pus  is  small  and 
walled  off  by  adhesions  from  the  general  pleural  cavity. 
These  loculated  empyemata  may  be  situated  between  the  lung 
and  the  chest  wall,  between  the  lung  and  the  diaphragm,  or  in 
the  spaces  between  the  lobes.  When  occurring  in  the  last 
two  regions,  their  diagnosis  may  be  attended  by  considerable 
difficulty. 

The  history  and  symptoms  may  suggest  the  presence 
of  pus,  and  on  examination  localized  tenderness,  dullness, 
'absent  breath-  and  voice-  sounds  surrounded  by  a  zone  of 
fine  rales,  bronchial-breathing,  and  increased  voice-sounds 
may  be  found.  The  .x--rays  may  be  of  considerable  value  in 
confirming  the  physical  signs  and  in  enabling  one  more 
accurately  to  localize  the  collection  of  pus  and  the  position  of 
the  diaphragm  and  heart.  When  the  evidence  points  to  a 
loculated  empyema,  an  exploratory  operation  is  to  be  pre- 
ferred to  exploratory  puncture,  on  account  of  the  difficulties 
attending-  the  exact  localization  of  the  pus.  The  operation 
should  be  attempted  only  by  an  experienced  surgeon,  as  it  is 
not  entirely  devoid  of  danger,  although  not  to  the  same  extent 
as  formerly,  owing  to  improvement  in  the  operative  methods 
applied  to  surgery  of  the  chest. 


526  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

The  operative  treatment  of  empyema  is  distinctly  a  sur- 
gical question,  the  most  important  object  being-  the  establish- 
ment of  free,  constant  drainage.  To  secure  this  usually  it  is 
necessary  to  remove  a  portion  of  several  ribs,  and  the  drain- 
age tube  should  be  constructed  or  arranged  so  as  to  prevent 
the  admission  of  air  as  much  as  possible. 

In  the  after-treatment  of  these  cases  the  building  up  of  the 
general  health  and  strength  of  the  patient  is  of  the  greatest 
importance.  The  re-expansion  of  the  lung  and  the  oblitera- 
tion of  the  pleural  space  previously  occupied  by  the  collection 
of  pus  may  be  materially  assisted  by  respiratory  exercises 
when  no  concomitant  disease  of  the  lung  forbids  this  measure. 

HEMORRHAGIC   PLEURITIS. 

The  presence  of  blood  in  a  pleural  effusion  is  most  fre- 
quently found  in  the  secondary  forms,  although  it  may  occur 
even  in  those  of  primary  type.  The  most  frequent  cause  is 
tuberculosis,  although  it  is  not  uncommon  in  those  due  to 
malignant  disease  of  the  lungs  and  pleura.  The  effusions  due 
to  pneumonia  may  be  blood-tinged,  also  those  due  to  severe 
infections,  or  occurring  during  the  course  of  chronic  asthenic 
diseases  or  in  purpura  hemorrhagica.  They  possess  very 
little  diagnostic  value,  and  their  occurrence  calls  for  no  special 
line  of  treatment  other  than  the  measures  ordinarily  applied 
to  effusions  in  general.  Even  the  blood-tinged  hydrothorax 
which  occasionally  occurs  during  the  course  of  the  cardiac  or 
renal  disease  has  no  special  significance,  and  calls  for  no 
particular  remedial  measures. 

PLEURAL   NEOPLASMS. 

The  occurrence  of  primary  carcinoma  and  sarcoma  of  the 
pleura  is  extremely  rare,  especially  the  latter,  the  disease  usu- 
ally arising  secondarily  to  malignant  disease  in  some  other 
part  of  the  body.  In  the  early  stages  there  is  no  feature  to 
distinguish  it  from  pleurisy  of  any  other  type,  although  usu- 
ally it  closely  resembles  that  due  to  tuberculosis.  The  symp- 
toms are  not  characteristic,  consisting  of  pain  on  deep  in- 
spiration, with  possibly  some  cough  and  dyspnea.     With  the 


PLEURAL    NEOPLASMS.  527 

accumulation  of  fluid  the  dyspnea  may  become  marked,  and  in 
the  later  stages  the  progressive  loss  and  strength  may  suggest 
the  presence  of  malignant  disease.  Fluid  is  almost  invariably 
present,  and  presents  no  signs  at  first  to  indicate  the  process 
responsible  for  its  accumulation.  The  diagnosis  of  malignant 
disease  of  the  pleura  is  mainly  reached  by  a  process  of  ex- 
clusion, although  occasionally  signs  which  suggest  its  pres- 
ence are  evident.  These  signs  depend  upon  the  presence  of 
thickening  of  the.  pleura  due  to  malignant  changes.  Any 
effusion  which  tends -to  accumulate  after  repeated  aspirations, 
and  in  which  there  is  no  evident  cause  for  the  presence  of  fluid, 
should  be  carefully  observed  as  a  possible  case  of  malignant 
disease.  This  is  especially  true  when  the  removal  of  the  fluid 
is  not  followed  by  a  decrease  of  the  flatness  and  an  increase 
in  the  amount  of  expansion  on  the  afl^ected  side.  When  the 
impairment  and  other  signs  of  thickened  pleura  persist  after 
the  removal  of  the  fluid  the  probability  of  malignant  disease 
is  very  strong,  particularly  should  the  chest  fail  to  expand, 
and  when  there  is  progressive  shrinking  of  the  affected  side. 
In  some  cases  the  resistance  offered  to  the  aspirating  needle 
is  of  such  a  character  as  to  indicate  the  presence  of  a  thickened 
pleura,  suggesting  a  tough,  grating,  .fibrous  tissue,  quite  dif- 
ferent from  the  soft,  smooth,  inflammatory  exudate  of  the 
non-malignant  conditions.  In  some  cases  small  nodular 
growths  may  arise  at  the  point  where  the  needle  has  been 
inserted  on  some  previous  occasion  for  the  withdrawal  of  the 
fluid,  from  an  extension  of  the  pleural  process  along  the  path 
of  the  needle.  When  these  nodules  are  found  they  should  be 
excised  and  examined  microscopically,  as  their  gross  appear- 
ance resembles  very  closely  that  of  the  nodules  which  mary 
arise  along  the  needle-path  in  tuberculous  effusions.  The  ex- 
amination of  the  fluid  occasionally  may  give  information  of 
value  in  arriving  at  a  correct  diagnosis  (see  Pleural  Fluids, 
p.  499).  A  careful  microscopic  study  of  sections  made  of  the 
small  plug  of  tissue  which  occasionally  occludes  the  aspirating 
needle,  has  in  some  cases  provided  information  upon  which 
a  positive  diagnosis  of  malignancy  could  be  based. 

The  treatment  of  a  pleural  malignant  neoplasm  is  extremely 
unsatisfactory,  for  it  consists  entirely  of  carrying  out  of  such 
measures  as  may  relieve  the  symptoms  temporarily.    Removal 


528  DISEASES    OF   THE    RESPIRATORY    SYSTEM. 

of  the  fluid  at  frequent  intervals  is  usually  conducive  to  the 
comfort  of  the  patient  by  relieving  the  cough  and  dyspnea. 
In  nearly  every  case  opium  and  its  derivatives  have  to  be  per- 
sistently employed  to  give  the  patient  relief  from  the  pain 
and  distress  which  eventually  supervene  in  practically  every 
case.  In  some  patients  the  removal  of  the  fluid  appears  to 
aggravate  the  symptoms,  rather  than  to  provide  relief,  and 
in  these  only  such  an  amount  of  fluid  should  be  withdrawn  as 
may  be  necessary  to  relieve  grave  pressure-symptoms.  In 
the  average  case  usually  it  is;  satisfactory  to  tap  the  chest  at 
fairly  frequent  intervals  to  prevent  the  accumulation  of  a  large 
amount  of  fluid,  the  repeated  removal  of  small  quantities  of 
fluid  proving  less  distressing  to  the  patient  than  the  with- 
drawal of  a  large  amount  at  single  seance. 

HYDROTHORAX. 

When  the  transudation  of  serous  fluid  into  the  pleural  cav- 
ity is  sufiQcient  in  amount  to  be  recognized  clinically,  it  is  usu- 
ally due  either  to  cardiac  or  to  renal  disease,  the  treatment  for 
the  relief  of  this  symptom  depending  upon  the  disease  respon- 
sible for  its  development..  When  the  fluid  persists,  in  spite  of 
the  correction  of  the  provocative  disease,  or  when  the  respira- 
tory or  circulatory  functions  are  seriously  interfered  with,  the 
fluid  should  be  aspirated,  with  extraordinary  precautions 
against  infections,  shock,  edema,  etc.,  as  stated  in  the  section 
on  Serofibrinous  Pleuritis  (see  p.  517).  The  physical  signs  of 
a  hydrothorax  are  the  same  as  those  of  any  other  collection  of 
fluid  in  the  pleural  space,  to  which  may  be  added  certain 
sy;nptoms  and  signs  incident  to  cardiorenal  and  cardiovas- 
cular diseases. 

HEMOTHORAX. 

This  name  should  be  reserved  for  those  cases  in  which 
there  is  an  actual  extravasation  of  blood  into  the  pleural  space, 
whether  due  to  injury  of  the  chest  wall  or  lung,  or  to  the 
rupture  of  a  large  vessel  in  the  mediastinum  or  chest  wall,  as 
a  result  of  erosin  or  aneurismal  dilatation.  The  mere  occur- 
rence of  a  blood-tinged  fluid  in  the  pleural  space  should  not 
be  considered  as  a  true  hemothorax. 


PNEUMOTHORAX.  529 

The  treatment  of  this  condition  is  purely  surgical  in  the 
large  majority  of  cases,  especially  as  they  are  most  commonly 
traumatic  in  origin.  If  the  hemorrhage  is  not  very  copious, 
the  consequent  hemothorax  may  be  completely  absorbed,  even 
when  fairly  large  coagulation  with  subsequent  absorption 
may  take  place ;  although  as  a  rule  the  absorption  is  not  com- 
plete, and  a  portion  of  the  clot  usually  undergoes  organization. 

The  principal  danger  in  this  condition  is  infection  of  the 
extravasated  blood,  which  is  particularly  prone  to  occur  when 
the  condition  is  due  to  trauma,  in  perforating  wounds  of  the 
chest  wall  or  rupture  of  the  lung. 

The  occurrence  of  hemorrhage  into  the  pleural  space  calls 
for  the  general  remedial  measures  applicable  to  hemorrhage  in 
any  other  part  of  the  body — surgical  measures  to  secure  the 
bleeding-point,  and  absolute  rest,  with  immobilization  of  the 
afifected  lung  by  adhesive  plaster  straps  to  the  chest.  If 
alarming  pressure-symptoms  develop,  thoracentesis  may  be- 
come necessary,  or  if  infection  of  the  effusion  becomes  evident 
one  may  have  to  resort  to  thoracotomy.    . 

CHYLOTHORAX. 

An  actual  chylothorax,  or  chylous  pleural  efifusion,  due  to 
pressure  upon,  or  rupture  of,  the  thoracic  duct,  should  not  be 
treated  by  aspiration  until  the  level  of  the  fluid  has  remained 
stationary  for  some  time,  or  the  pressure-symptoms  have  de- 
come  so  grave  as  to  demand  interference.  When  the  effusion 
is  merely  chyliform,  and  due  to  fatty  degenerative  processes, 
or  to  the  presence  of  some  albuminoid  substance,  the  treat- 
ment should  be  that  of  the  ordinary  effusion.  The  diagnosis 
of  this  form  of  pleural  effusion  can  be  made  only  by  an  ex- 
amination of  the  fluid  obtained  by  exploratory  puncture  or 
aspiration. 

PNEUMOTHORAX. 

This  condition  consists  in  the  presence  of  atmospheric  air 
or  gas  within  the  pleural  sac.  The  lung  is  an  elastic  org-an 
held  in  apposition  to  the  chest  wall  by  the  negative  pressure 
within  the  pleural  space.  The  entrance  of  atmospheric  air 
into  the  pleural  space  results  in  collapse  of  the  lung-  through 

34 


530  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

destruction  of  the  intrapleural  negative  pressure,  which  main- 
tains the  surface  of  the  lung  in  close  apposition  with  the  chest 
wall,  permitting  it  to  contract  by  reason  of  its  normal  elas- 
ticity. Pneumothorax  should  not  be  looked  upon  as  a  com- 
pression of  the  lung  by  air-pressure,  but  rather  as  a  removal 
of  the  force  which  has  maintained  the  contractile  lung  in  a 
position  of  overdistension.  As  atmospheric  air  is  compara- 
tively rapidly  absorbed  from  the  pleural  cavity,  one  may 
readily  understand  that  the  course  of  this  process  may  vary 
with  the  exciting  conditions,  depending  upon  whether  the 
opening  which  forms  communication  between  the  pleural 
space  and  the  outer  air  through  the  lung  or  chest  wall  persists, 
is  quickly  closed,  or  isi  valvular  in  character. 

Atmospheric  air  may  gain  entrance  to  the  pleural  space 
through  the  chest  wall,  as  a  result  of  penetrating  wounds  (gun- 
shot wounds,  stab  wounds,  thoracotomy,  thoracentesis,  etc.)  ; 
or  from  perforation  of  the  pulmonary  pleura  and  lung,  trachea, 
bronchi,  stomach,  esophagus,  or  intestines,  as  a  result  of 
trauma  or  disease.  Rarely,  pneumothorax  may  result  from 
the  formation  of  gas  by  certain  types  of  micro-organisms  de- 
veloping in  pleural  effusions,  as  cases  have  been  reported  in 
which  gas-forming  bacteria  in  pleural  effusions  have  appeared 
to  be  responsible  for  the  formation  of  the  pneumothorax. 

From  a  clinical  standpoint,  interest  is  chiefly  centered  in 
the  cases  due  to  perforation  of  the  lung  as  a  result  of  disease. 
By  far  the  commonest  cause  of  this  type  of  pneumothorax  is 
pulmonary  tuberculosis,  but  it  may  occur  rarely  in  pul- 
monary abscess,  gangrene,  bronchiectasis,  infarction,  malig- 
nant disease,  empyema,  or  possibly  emphysema.  A  few  cases 
have  been  reported  in  which  a  pneumothorax  developed  from 
rupture  of  the  lung  in  persons  who  were  apparently  in  per- 
fect health,  or  in  whom  there  was  no  evidence  of  any  disease 
capable  of  producing  pneumothorax.  Apparently  here  it 
arose  as  a  result  of  some  unusual  violent  exertion,  such  as 
coughing,  sneezing,  laughing,  and  in  those  exceptional  in- 
stances where  it  developed  while  the  subject  was  at  rest,  or 
even  asleep,  no  tangible  factor  could  be  discovered. 

The  conditions  arising  after  the  entrance  of  air  to  the 
pleural  space  are  dependent  upon  whether  the  pleura  is  free 
or  partially  adherent,     ^^'hen  the  pleura  is  free  the  lung  col- ' 


PNEUMUTllURAX.  531 

lapses  completely,  retracting  toward  the  root  of  the  lung,  and 
at  autopsy  it  may  be  found  as  a  small  shrunken  mass  lying 
against  the  spinal  column.  When  adhesions  are  present,  their 
location  and  extent  regulate  the  degree  of  collapse,  and  the 
situation  of  the  accumulation  of  air.  Usually  the  collapsed 
lung  is  the  seat  of  a  distinct  tuberculous  process,  in  which 
case  the  perforation  can  be  easily  demonstrated,  commonly  in 
the  wall  of  a  superficial  cavity.  As  the  perforation  in  the 
lung  is  usually  the  result  of  disease,  infective  material  fre- 
quently, gains  entrance  to  the  pleural  space,  and  results  in 
hydropneumothorax,  pyopneumothorax,  or  rarely  hemopneu- 
mothorax.  It  is  exceedingly  rare  to  find  a  pneumothorax 
which  has  existed  for  any  length  of  time  in  which  fluid  is  not 
present.  The  presence  of  air  in  the  pleural  space  is  usually 
accompanied  by  displacement  of  the  heart,  diaphragm,  liver, 
spleen,  and  even  the  opposite  lung. 

The  onset  of  the  disease  varies  greatly,  although,  as  a  rule, 
it  occurs  suddenly  with  violent,  sharp  pain,  severe  dyspnea, 
and  an  intense  air-hunger  and  sense  of  suiTocation.  In  other 
patients  there  are  merely  slight  pain  and  moderate  dyspnea, 
or  symptoms  may  be  entirely  absent,  and  the  condition  dis- 
covered only  in  the  course  of  routine  examination.  The 
severity  of  the  symptoms  at  the  onset  of  the  disease  probably 
are  largely  dependent  upon  the  degree  of  collapse  of  the  lung 
as  controlled  by  the  extent  of  adhesions. 

While  small  quantities  of  air  in  the  pleural  space  may  be 
dififiicult  to  detect,  in  the  average  case  the  signs  are  so  charac- 
teristic and  striking  that  the  condition  is  easily  recognized. 
On  inspection  usually  there  are  evidences  of  dyspnea,  immo- 
bility of  the  affected  chest,  distended,  bulging  interspaces,  ab- 
sence of  the  diaphragm  shadow,  and  possibly  displacement  of 
the  heart,  as  recognized  by  the  abnormal  position  of  the  apex- 
beat.  Vocal  fremitus  is  absent,  and  displacement  of  the  solid 
viscera  may  be  determined  by  palpation.  The  percussion- 
sound  is  usually  hyperresonant,  loud,  and  low-pitched ;  al- 
though when  the  pulmonary  opening  is  large  and  patulous  the 
note  may  be  tympanitic,  or  if  the  air  in  the  pleura  is  under 
.very  great  tension,  as  may  occur  when  the  opening  is  valvular, 
the  sound  may  be  dull.  The  area  of  hyperresonance  ma}'  ex- 
tend beyond  the  median  line,  encroaching  upon  the  normal 


532  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

side.  Percussion  also  may  be  employed  to  confirm  the  dis- 
placement of  the  heart,  or  suggest  the  presence  of  fluid  by  the 
area  of  flatness  at  the  base.  The  breath-sounds  are  decidedly 
suppressed  or  absent,  althoug-h  occasionally  amphoric  breath- 
ing is  audible  together  with  rales  of  a  distant,  amphoric  qual- 
ity. The  most  striking  and  characteristic  phenomena  are  the 
metallic  tinkle,  the  succussion  splash,  and  the  coin-test.  In 
the  early  cases  without  fluid  usually  the  first  suggestive 
group  of  signs  is  absence  of  breath-  and  voice-  sounds,  dis- 
tension and  immobility  of  the  chest,  and  hyperresonance  on 
percussion.  The  .t'-rays  are  of  considerable  value  in  deter- 
mining the  presence  of  small  collections  of  air,  and  for  con- 
firming the  diagnosis  of  pneumothorax  in  doubtful  cases. 
The  presence  and  amount  of  fluid  in  these  cases  may  also  be 
conveniently  studied  by  the  .r-rays.  In  the  average  case 
radiology  is  unnecessary,  the  physical  signs  alone  being  usu- 
ally sufficient  to  determine  the  size  and  location  of  the  pneu- 
mothorax and  the  quantity  of  fluid. 

TREATMENT. 

The  treatment  of  pneumothorax  depends  upon  the  cause 
of  the  condition,  the  presence  or  absence  of  disease  in  the 
lung,  and  the  amount  and  character  of  the  effusion  which  so 
commonh-  accompanies  the  process.  The  medical  care  of 
pneumothorax  may  be  conveniently  described  under  two  head- 
ings, one  for  the  relief  of  symptoms,  and  the  other  such  meas- 
ures as  may  be  directed  toward  assuring  the  closure  of  the 
opening  through  which  the  air  gains  entrance  to  the  pleura. 

When  due  to  the  entrance  of  atmospheric  air  from  an 
opening  in  the  chest  wall  or  through  a  healthy  lung,  the  treat- 
ment consists  chiefly  of  relieving  symptoms,  securing  absolute 
rest  of  the  lung,  and  applying  measures  designed  to  prevent 
infection  and  hemorrhage.  The  large  majority  of  such  cases 
tend  to  heal  spontaneously  when  mereh^  kept  at  rest.  Rest 
in  bed,  strapping  of  the  chest,  relieving  grave  pressure-symp- 
toms by  release  of  a  moderate  amount  of  the  air,  and  sufficient 
morphin  to  relieve  pain  and  to  control  distressing  cough,  is 
usually  sufficient.  In  removing  by  thoracentesis  the  air  en- 
closed in  the  pleural  space  as  a  result  of  rupture  of  the  lung, 
care  must  be   exercised   not  to   exhaust  the   air   completely, 


PNEUMOtHORAX.  53,^ 

since  a  certain  amount  of  pressure  is  necessary  to  maintain  a 
closure  of  the  pleuro-pulmonary  fistula.  In  those  cases 
in  which  the  condition  develops  very  rapidly,  w^ith  severe 
dyspnea,  cyanosis,  and  evidence  of  cardiac  failure  or  suffoca- 
tion, the  removal  of  a  certain  amount  of  air  by  thoracentesis 
is  necessary  in  order  to  save  life.  When  wounds  of  the  chest 
are  the  factor,  such  steps  must  be  taken  as  will  check  any 
tendency  to  bleeding",  and  cleanse  the  wound  of  infective 
material.  When  atmospheric  air  has  gained  entrance  to  the 
pleura  through  a  non-patulous  opening-  that  does  not  leak  con- 
tinuously, the  intrapleural  air  tends  rapidly  to  become  ab- 
sorbed. It  is  only  when  additional  quantities  of  ajr  are  con- 
stantly being  added  to  that  already  within  the  pleura  that  a 
pneumothorax  persists. 

The  most  frequent  cause  of  pneumothorax  is  pulmonary 
tuberculosis,  in  which  a  small  subpleural  cavity  or  caseating 
area  ruptures  into  the  pleura  and  leaves  a  patulous  opening, 
through  which  air  gains  entrance  to  the  pleural  space ;  or  the 
opening  may  be  valvular,  in  which  case  air  may  readily  gain 
entrance  to  the  pleura,  but  is  prevented  from  returning.  The 
usual  location  of  the  air  collection  is  not  at  the  apex,  as'  one 
would  expect,  but  over  the  lower  portion  of  the  lung,  as  the 
upper  part  of  the  lung  is  usually  adherent  to  the  chest  wall. 
In  these  cases  not  only  air,  but  infective  material  fronr  the 
diseased  lung,  gains  entrance  to  the  pleural  space,  so  that  the 
pneumothorax  usually  is  complicated  by  a  serous  or  purulent 
efifusion.  A  moderate  amount  of  serous  effusion  should  never 
be  disturbed  in  these  cases,  as  it  not  infrequently  aids  in 
securing  closure  of  the  opening  in  the  lung.  Even  when  the 
effusion  becomes  massive,  great  care  must  be  used  in  with- 
drawing the  fluid ;  in  such  instances  it  is  best  to  aspirate  suffi- 
cient merely  to  relieve  pressure-symptoms,  for  the  entire 
effusion  should  never  be  withdrawn  so  long  as  there  is  a  pos- 
sibility of  reopening  the  pulmonary  fistula. 

When  pyopneumothorax  develops,  however,  the  presence 
of  a  large  quantity  of  pus  of  itself  constitutes  such  a  serious 
menace  to  life  and  health  that  its  removal  is  imperative,  either 
by  thoracentesis  or  by  open  operation  and  drainage,  according 
to  character  of  the  pus  and  the  evidence  of  absorption  of 
toxic  material  by  the  patient.     When  the  quantity  of  pus  is 


534  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

small,  and  there  are  no  signs  pointing-  toward  a  general  tox- 
emia, it  may  be  allowed  to  remain  undisturbed  until  suffi- 
cient time  has  elapsed  to  permit  a  closure  of  the  opening  in 
the  lung. 

It  has  been  recommended  that  in  the  cases  of  pulmonary 
tuberculosis  complicated  by  pneumothorax,  when  serofibrin- 
ous or  purulent  effusions  develop,  their  removal  may  be  ac- 
complished even  before  the  opening  in  the  lung  has  had  a 
chance  to  close  by  replacing  the  fluid  with  nitrogen  gas.  The 
fluid  is  withdrawn  and  nitrogen  gas  introduced  simultane- 
ously, maintaining  by  this  means  a  constant  pressure  within 
the  pleural  space,  this  pressure  being  controlled  during  the 
exchange  by  the  use  of  the  water  manometer.  This  procedure 
has  many  points  to  recommend  it,  not  the  least  of  which  is  the 
advantage  obtained  by  the  compression  of  the  lung  upon  the 
tuberculous  process.  A  sufficient  number  of  cases  favorably 
treated  by  this  method  have  been  reported  to  warrant  its 
being  more  generally  adopted  (see  Tuberculosis-Pneumo- 
thorax.  p.  462). 

BACTERINS    IN    THE    TREATMENT    OF    DISEASES 
OF   THE   LUNGS,    BRONCHI,    AND    PLEURA. 

Throughout  the,  text  repeated  reference  has  been  made  to 
the  use  of  bacterial  vaccines  or  bacterins  in  certain  diseases  of 
the  bronchopulmonary  system,  and  it  seems  advisable  to  con- 
sider the  subject  a  little  more  fully  in  a  special  section,  on 
account  of  the  rather  general  adoption  of  this  method  of 
treatment.  The  subject  is  one  which  one  hesitates  to  discuss, 
as  it  is  difficult  to  estimate  its  value,  and  in  view  of  the  many 
reported  cases  in  w-hich  it  is  difficult  to  determine  how  much 
could  be  credited  to  the  employment  of  bacterins  and  how 
much  to  other  measures.  The  administration  of  bacterins  in 
self-limited  diseases,  or  those  in  which  abortive  types  are  fre- 
quently encountered,  is  another  possible  source  of  error.  The 
writer  does  not  believe  that  it  has  been  absolutely  demon- 
strated beyond  question  that  the  injection  of  bacterins  is  abso- 
lutety  without  danger  in  many  of  the  bronchopulmonary  dis- 
eases in  the  treatment  of  which  they  have  been  recommended. 

In  the  first  place  the  most  serious  difficulty  lies  in  securing 
a  culture  of  the  one  or  several  micro-organisms  responsible  for 


BACtERINS.  335 

the  disease.  The  various  methods  for  washing  the  sputum  in 
repeated  changes  of  water,  preceded  by  careful  cleansing  of 
the  mouth  and  pharynx,  have  added  consideral^ly  to  our  al^lity 
to  obtain  secretion  from  the  bronchial  tract  with  little  or  no 
contamination.  Having  obtained  a  specimen  of  bronchial 
secretion,  the  problem  still  remains  of  determining  which 
bacterium  or  group  of  bacteria  is  responsible  for  the  process. 
The  discovery  of  micro-organisms  in  pure  culture  under  such 
conditions  may  be  said  practically  never  to  occur.  The  cus- 
tom has  been  to  make  up  a  mixture  of  the  various  recognized 
pathogenic  micro-organisms  isolated,  and  to  prepare  a  final 
bacterin  containing  a  definite  proportion  of  each,  so  that  the 
dose  of  each  germ  may  be  accurately  estimated.  By  this 
method  the  relative  number  of  each  type  of  micro-organism 
is  definitely  fixed,  inasmuch  as  it  is  impossible  to  vary  the  pro- 
portion of  any  one  type  or  to  omit  any  if  it  should  seem  desir- 
able. The  preparation  of  bacterins  from  each  single  type  of 
bacterium  seems  to  obviate  this  objection,  but  it  makes  their 
administration  much  less  convenient.  It  has  been  recom- 
mended that  a  careful  study  be  repeatedly  made  during  a 
course  of  treatment  by  mixed  bacterins,  so  that  the  adminis- 
tration of  certain  micro-organisms  might  be  discontinued  as 
they  were  found  to  have  disappeared  from  the  sputum.  The 
question  of  treatment  by  means  of  bacterins  would  be  very 
much  simplified  if  one  could  be  certain  that  the  predominating 
micro-organism  was  the  most  important  etiologic  factor,  but 
apparently  this  is  not  the  case.  Further  confusion  is  caused 
by  the  fact  that  certain  micro-organisms  require  the  presence 
of  other,  apparently  innocuous,  bacteria  before  they  are 
capable  of  setting  up  a  morbid  process. 

The  list  of  germs  capable  of  causing  infection  of  the  re- 
spiratory tract  is  gradually  increasing  in  numbers;  seemingly 
among  the  most  important  are  the  pneumococcus,  strepto- 
coccus, influenza  bacillus,  bacillus  septus,  micrococcus  catar- 
rhalis,  staphylococcus,  micrococcus  tetragenes,  pyocyaneus 
bacilli,  bacillus  coli,  bacterium  aerogenes,  mucosus  group,  and 
the  typhoid  bacillus.  The  relative  frequency  with  which  they 
are  found  in  diseases  of  the  respiratory  tract  varies  from  year 
to  year.  The  futility  of  employing  stock  bacterins  in  the 
treatment  of  any  disease  of  the  respiratory  tract  must  be  per- 


536  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

fectly  obvious,  unless  a  thoroug-h  study  of  the  case  should 
happen  to  reveal  a  condition  of  affairs  in  which  the  stock  vac- 
cine is  peculiarl}^  and  specially  applicable. 

The  most  that  can  be  expected  from  the  use  of  vaccines  in 
acute  conditions  is  a  limitation  of  the  disease,  and  in  any 
infectious  condition  their  only  possible  utility  is  in  increasing- 
resistance  to  the  invading  micro-organisms,  which  in  many 
diseases  of  the  respiratory  tract  is  only  one  of 'several  condi- 
tions which  call  for  treatment.  In  recent  years  we  have  be- 
come so  accustomed  to  view  disease  from  the  standpoint  of  the 
infecting  micro-organisms  alone,  that  the  response  to  or  effect 
upon  the  tissue  of  the  host  has  been  somewhat  ignored.  To 
cite  an  example,  in  acute  bronchitis  the  mere  overcoming  of 
the  invading  bacteria  is  in  itself  not  sufffcient  to  restore  the 
function  of  the  bronchi  in  many  instances,  and  the  cases  usu- 
ally require  further  treatment  to  establish  a  cure.  In  no  case 
should  vaccines  be  employed  to  the  exclusion  of  the  regular 
methods  of  treatment. 

In  the  employment  of  bacterins  for  therapeutic  purposes 
there  are  certain  cases  in  which  one  must  proceed  cautiously. 
This  is  true  of  persons  who  give  a  history  of  sensitization  to 
foreign  proteins,  whether  shown  by  severe  reaction  to  variola 
vaccination,  susceptibility  to  the  presence  of  horses  or  small 
rodents,  or  cutaneous  reactions  to  various  foodstuff's.  In  pa- 
tients in  whom  there  is  marked  cardiac  or  renal  disease,  or 
those  who  are  rapidly  progressing  toward  a  fatal  termination, 
with  marked  asthenia,  bacterin  treatment  should  never  be 
employed.  Anv  acute  conditions  of  the  kidney's,  as  evidenced 
by  blood,  casts,  and  albumin  in  the  urine,  constitutes  a  dis- 
tinct contraindication  to  their  use.  In  diseases  of  the  respira- 
tor}^ tract  the  administration  of  bacterins  is  especially  likely 
to  be  followed  by  an  increase  of  symptoms  and  signs,  which 
may  prove  a  very  serious  matter  in  such  conditions  as  capil- 
lary bronchitis,  or  the  bronchopneumonia  of  children.  Pa- 
tients being  treated  by  bacterins  should  be  warned  of  the 
probability  of  an  aggravation  of  symptoms  after  the  first 
injection. 

Space  will  not  permit  of  describing  in  detail  the  various 
micro-organisms,  dosage,  etc.,  to  be  employed  in  every  dis- 
ease of  the  respiratory  tract,  but  there  are  a  few  general  rules 


BACTERINS.  537 

and  precautions  which  may  be  given.  Great  care  should  be 
exercised  in  the  preparation  of  the  bacterin  to  see  that  the 
numerical  proportion  of  bacteria  to  the  definite  amount  of 
solution  be  accurately  ascertained,  so  that  the  dosage  may  be 
exactly  gauged.  One  must  be  positive  that  the  bacterin  is 
absolutely  sterile — that  the  micro-organisms  contained  therein 
are  not  viable.  The  original  suspension  of  the  bacteria  should - 
be  made  as  concentrated  as  possible,  dilutions  being  made 
from  this  stock  solution  at  the  time  of  the  injection.  Unless 
the  suspension  is  concentrated,  disintegration  of  the  bacteria 
takes  place  rapidly.  The  bacterin  should  be  prepared  so  that 
the  number  of  bacteria  may  be  estimated  on  the  basis  of  a 
mil  or  a  decimal  thereof,  as  most  of  the  syringes  used  for  the 
injection  are  scaled  according  to  the  metric  system. 

The  injections  should  be  made  in  the  loose  subcutaneous 
tissue  at  a  point  where  there  is  no  pressure  from  the  clothing, 
the  arm  and  infraclavicular  regions  being  very  convenient  sites 
for  the  operation.  The  injected  material  should  be  well  spread 
out  under  the  skin,  unless  there  is  fear  that  the  reaction  will 
be  pronounced.  Under  this  circumstance  the  material  should 
be  allowed  to  remain  at  one  point  so  that  absorption  will  be 
slow ;  with  this  technic  the  local  reaction  may  thus  be  more 
marked,  but  the  general  reaction  will  be  milder.  The  injec- 
tions should  be  given  before  three  o'clock  in  the  afternoon,  so 
that  slight  reactions  in  the  first  eight  hours  may  be  observed. 

The  dosage  varies  in  dififerent  conditions  and  with  various 
micro-organisms,  but  a  few  general  rules  may  be  given  as 
follows :  When  the  extent  of  the  lesions  is  great  the  individual 
doses  should  be  small,  and  large  doses  should  be  given  when 
the  focus  of  disease  is  small.  When  the  part  affected  has  a 
rich  blood-supply  small  doses  are  indicated,  and  when  it  has 
a  poor  blood-supply  large  doses  should  be  used.  No  reinjec- 
tion  should  be  given  while  there  is  any  evidence  of  the  pre- 
vious injection.  The  dose  should  never  be  increased  so  long 
as  the  condition  is  improving.  The  first  and  second  doses 
should  never  be  given  during  the  menstrual  period.  The  dose 
should  be  sufficient  to  produce  a  mild  reaction,  as  evidenced 
by  an  increase  of  secretion  from  the  mucous  membrane  of  the 
part  affected,  and  severe  reactions  should  be  avoided.  The 
evidence  of  reaction  may  be  taken  to  determine  the  intervals 


538  DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

between  doses,  reinjection  never  to  be  made  sooner  than 
twenty-four  hours  or  later  than  seventy-two  hours  after  all 
the  effects  of  the  previous  injection  shall  have  disappeared. 
A  moderate  increase  in  the  number  of  leucocytes  in  the  cir- 
culating blood  at  the  end  of  twenty-four  hours  has  a  favorable 
significance,  but  if  the  count  of  these  cells  diminishes  the  suc- 
■  ceeding  dose  should  be  less  than  the  one  preceding. 

In  conclusion  it  may  be  stated  that  the  results  from  bac- 
terin  treatment  are  frequently  disappointing,  occasionally 
striking,  and  in  some  instances  unfavorable.  The  cases  which 
are  most  resistant  to  the  ordinary  methods  of  treatment,  such 
as  bronchiectasis  and  the  chronic  bronchitis  of  emphysema, 
in  which  much  good  was  anticipated  from  the  use  of  bac- 
terins,  unfortunately  constitutes  a  group  in  which  they  seem 
to  be  of  the  least  value.  Probably  the  use  of  bacterins  event- 
ually will,  be  found  to  be  of  value  for  the  prevention  of  acute 
diseases  of  the  respiratory  tract,  rather  than  for  therapeutic 
purposes.  Before  this  hope  is  placed  upon  a  firm  basis,  there 
will  have  to  be  many  careful  studies  of  the  bacteriology  of 
these  processes,  an  improvement  in  our  methods  of  determin- 
ing the  causative  micro-organisms  in  the  individual  case,  and 
possibly  a  more  accurate  method  evolved  for  the  determina- 
tion of  the  proper  mode  of  application,  so  far  as  the  dosage 
and  frequency  of  administration  are  concerned. 

The  writer  begs  to  acknowledge  his  indebtedness  to  Dr. 
Herbert  Fox  for  much  of  the  material  upon  which  the  fore- 
going section  is  based,  at  the  same  time  expressing  his  re- 
grets that  he  finds  himself  unable  (possibly  on  account  of  a 
more  limited  experience  with  this  method  of  treatment)  to 
share  with  Dr.  Fox  his  optimistic  views  in  regard  to  the  value 
of  bacterin  treatment. 


Diseases  of  the  Kidneys 

BY 

JUDSON  DALAND,  M.D., 

Professor  of  Clinical  Medicine,  Graduate  School  of  Medicine,  Univer- 
sity   of    Pennsylvania, 

AND 

FRANCIS   J.    DEVER,    M.D., 
Formerly  Associate  Professor  of  Clinical  Medicine,  Medico-Chirurgical 
College;    Assistant  Visiting    Physician;    Philadelphia    General    and 
Medico-Chirurgical  Hospitals, 


(539) 


Diseases  of  the  Kidneys. 


FOREWORD. 

Preceding  the  discussion  of  diseases  of  the  kidneys,  a  small 
amount  of  space  is  devoted  to  the  essential  features  of  the 
gross  and  minute  anatomy  of  these  organs.  A  lengthy  discus- 
sion of  the  various  theories  of  the  mechanism  of  the  urinary 
secretion  is  avoided ;  but  a  brief  summary  of  the  modern  views 
of  renal  physiology  is  presented.  The  normal  urine  is  de- 
scribed, and  simple  tests  are  given  for  the  detection  of  the  vari- 
ous normal  constituents. 

A  classification  of  movable  kidney  is  made  based  upon  the 
degree  of  mobility.  A  word  of  warning  is  given  against  at- 
taching undue  importance  ta  the  accidental  discovery  of  mov- 
able kidney.  Operation  is  believed  to  be  contraindicated,  ex- 
cept under  a  few  well  defined  circumstances.  Treatment  along 
the  lines  of  general  upbuilding,  with  exercises  to  increase  the 
tone  of  the  abdominal  muscles,  is  described.  The  wearing  of 
a  belt  designed  to  keep  the  kidney  in  place  is  viewed  as  a  tem- 
porary measure,  to  be  employed  only  until  the  abdominal 
muscles  can  be  developed  by  appropriate  exercises  and  the 
emacia'ted  fattened. 

It  is  rarely  possible,  clinically,  accurately  to  differentiate 
the  different  types  of  nephritis  described  by  the  pathologist. 
Indeed,  the  pathologist  is  unable  at  times  to  decide  to  which 
type  a  particular  pair  of  kidneys  belong  when  he  has  them  in 
his  hands  for  examination.  Therefore  it  is  deemed  sufficient, 
from  the  standpoint  of  treatment,  to  classify  nephritis  as :  (a) 
acute  parenchymatous  or  acute  diffuse  nephritis ;  (b)  chronic 
parenchymatous  or  diffuse  nephritis  without  induration;  and 
(c)  chronic  interstitial  or  chronic  diffuse  nephritis  with  indura- 
tion. The  arteriosclerotic  kidney  is  considered  with  chronic 
interstitial  nephritis. 

The  importance  of  focal  sepsis  as  a  cause  of  acute  nephritis, 
and  ultimately  chronic  nephritis  through  frequent  recurrences, 

(541) 


542  DISEASES    OF    THE    KIDNEYS. 

is  emphasized.  Aluch  information  of  value  in  prognosis  and 
treatment  is  derived  from  a  study  of  the  function  of  the  kidney 
in  disease.  No  one  test  alone  is  capable  of  throwing"  sufficient 
light  upon  the  function  of  the  kidney  as  a  whole.  It  is  there- 
fore recommended  that  the  ability  of  the  kidney  to  excrete  the 
dye,  phenolsulphonep'hthalein,  and  also  the  degree  of  retention 
in  the  blood  of  uric  acid,  urea,  and  creatinin,  be  studied.  A 
technic  for  these  tests  is  given,  and  the  use  of  a  test  diet,  ac- 
cording to  the  method  described  by  Mosenthal,  is  described. 
Tests  for  albumin,  blood,  etc.,  in  the  urine  are  given,  and  the 
significance  of  casts  and  cylindroids  is  discussed. 

No  mention  of  certain  drugs  and  combinations,  still  in  great 
vogue,  is  made  under  the  heading  of  treatinent  of  nephritis, 
because  the  authors  believe  them  to  be  without  value.  Certain 
other  drugs  are  condemned  because  their  use  is  likely  to  irri- 
tate still  further  the  diseased  kidneys.  Diet  and  elimination 
through  the  skin  occupy  an  important  place  in  the  treatment, 
and  the  technic  of  the  various  measures  employed  by  the 
authors  is  described.  The  treatment  of  the  various  clinical 
types  of  Bright's  disease  is  discussed  in  detail. 

In  addition,  consideration  is  given  to  renal  lithiasis,  pyo- 
genic infections,  hydronephrosis,  and  renal  tuberculosis. 

GENERAL    CONSIDERATIONS. 

Briefly  to  rehearse  the  chief  features  of  the  dinicQl  anat- 
omy of  the  kidneys,  it  will  be  recalled  that  they  lie  behind 
the  peritoneum  in  a  mass  of  fat  and  loose  areolar  tissue, 
alongside  the  vertebral  column,  opposite  the  twelfth  thoracic, 
and  the  first,  second  and-  third  lumbar  vertebrae.  They  are 
approximately  4^  inches  (11.5  cm.)  long,  2  to  2^  inches  (5.08 
to  6.3  cm.)  broad,  and  1^  inches  (3.8  cm.)  thick,  and  weigh 
43/2  to  6  ounces  (139.9  to  186.6  Gm.).  The  kidneys  of  females 
weigh  a  trifle  less.  Immediately  above  the  kidneys  lie  the 
suprarenal  glands. 

The  anterior  surface  of  the  right  kidney  is  in  relationship 
with  the  inferior  surface  of  the  liver,  the  second  part  of  the 
duodenum,  small  intestine  and  the  hepatic  flexure  of  the 
colon.  The  part  of  the  kidney  in  relation  with  the  liver  and 
intestine    is    covered    by    peritoneum,   while    that    portion    in 


GENERAL   CONSIDERATIONS.  543 

relation  with  the  duodenum  and  colon  is  devoid  of  a  per- 
itoneal investiture. 

The  anterior  surface  of  the  left  kidney  is  in  relation  with 
spleen,  stomach,  pancreas,  small  intestine,  and  splenic  flex- 
ure of  the  colon.  The  area  in  contact  with  the  stomach  is 
covered  by  peritoneum  of  the  lesser  sac ;  that  in  relation  to 
the  small  intestine  by  the  peritoneum  of  the  greater  sac. 

The  posterior  surface,  entirely  devoid  of  peritoneal  cov- 
ering, lies  upon  the  diaphragm,  the  lumbar  aponeurosis,  the 
arcuate  ligaments,  the  psoas  and  transversalis  muscles,  the 
last  thoracic,  iliohypogastric,  and  ilioinguinal  nerves.  The 
diaphragm  separates  the  kidney  and  pleura,  but  very  com- 
monly the  diaphragmatic  fibers  are  defective  or  absent,  so 
that  the  perirenal  alveolar  tissue  is  in  contact  with  the  dia- 
phragmatic pleura. 

In  the  funnel-shaped  cavity  of  the  renal  pelvis  is  the 
ureter  which,  passing  over  the  psoas  muscle,  converges 
toward  the  ureter  of  the  opposite  kidney  and  passes  obliquely 
through  the  wall  of  the  bladder.  It  is  a  musculo-membran- 
ous  tube,  the  upper  end  of  which  is  expanded,  and  within 
the  renal  pelvis,  divides  into  a  number  of  short  tubes  called 
calyces,  each  of  which  embraces  the  apex  of  a  Malpighian 
pyramid.  The  capacity  of  the  renal  pelvis  is  from'  5  to  15 
mils  (1.3  to  4.0  fo). 

The  kidneys  are  held  in  position  by  the  apposition  of  the 
neighboring  viscera  and  the  fascia  renalis,  which  blends  with 
the  fascia  on  the  quadratus  lumborum  and  psoas  muscles, 
and  thus  is  attached  to  the  vertebral  column.  Above,  the 
fascia  blends  with  the  fascia  of  the  diaphragm.  A  smooth 
firm  covering  of  fibrous  connective  tissue  forms  the  renal 
capsule,  which  strips  easily,  leaving  a  smooth,  even  surface, 
deep  red  in  color.  The  capsule  enters  the  hilum  of  the  kid- 
ney, blending  with  the  connective  tissue  carried  in  with  the 
vessels  and  nerves. 

The  renal  substance  is  divisible  into  an  outer  portion,  the 
cortex,  which  is  %  to  ^^  an  inch  (8.4  to  12.7  mm.)  in  thickness; 
and  an  inner  portion,  the  medulla,  which  is  %  to  %  of  an 
inch  (16.9  to  19.05  mm.)  thick. 

The  cortex  lies  irnmediately  beneath  the  capsule,  and 
sends   projections   toward   the   sinus,   between   the   pyramids, 


544  DISEASES   OF   THE   KIDNEYS. 

forming  the  columns  of  Bertini.  It  is  made  up  of  the  con- 
voluted and  straight  tubules,  Malpighian  bodies,  blood  ves- 
sels, nerves,  lymphatic  and  connective  tissue.  The  straight 
tubules  are  lighter  colored  than  the  rest  of  the  cortical  struc- 
ture, and  are  visible  as  ray-like  prolongations  (medullary 
rays)  extending  toward  the  external  surface  of  the  cortex. 

The  medulla  is  made  up  of  the  pyramids  of  Malpighi,  of 
which  there  are  from  eight  to  twenty.  They  are  composed 
of  the  straight  collecting  tubules,  and  part  of  the  ascending 
and  descending  limbs  and  loops  of  Henle. 

For  their  blood  supply  the  kidneys  depend  upon  the  renal 
arteries,  which  are  given  off  from  the  abdominal  aorta.  Just 
before  entering  the  kidneys  through  the  hilum,  each  artery 
divides  into  four  or  five  branches  which  enter  the  substance 
of  the  organ  between  the  pyramids.  At  the  juncture  of  the 
cortex  and  medulla  the  arteries  run  a  course  about  parallel 
with  the  surface  of  the  kidney,  giving  off  branches  to  the 
cortex  and  medulla.  The  branches  to  the  cortex  send  off 
twigs  to  each  Malpighian  corpuscle. 

The  nerve  supply  is  through  the  renal  plexus,  which  is 
formed  by  branches  from  the  solar  plexus,  the  lower  and 
outer  part  of  the  semilunar  ganglion  and  aortic  plexus,  and 
from  the  lesser  splanchnic  nerves.  The  nerves  of  the  kidney 
communicate  with  the  spermatic  plexus.  The  spinal  seg- 
m.ents  corresponding  to  the  kidney  and  the  ureter  are  the 
tenth,  eleventh  and  twelfth  dorsal  and  first  lumbar. 

Little  or  no  motor  force  is  supplied  by  the  nerves  to  the 
renal  pelvis.  Sensation  probably  is  not  ver}^  acute,  as  is 
demonstrated  by  the  slight  response  to  the  presence  of  the 
tip  of  a  catheter,  or  slight  distension  of  its  walls  by  fluid. 
When  the  stimulation  is  sufficiently  great  the  response  is 
obtained  not  only  from  the  renal  pelvis,  but  from  the  entire 
urinary  tract  as  well. 

The  arteries  which,  form  the  Malpighian  corpuscles  in  the 
cortex  end  in  a  tuft  of  convoluted  capillaries,  which  are  sur- 
rounded, or,  more  correctly  speaking,  invaginated,  by  a 
hyaline  membrane  called  the  capsule  of  Bowman.  From  this 
capsule  is  given  off  a  narrow  tubule  which  soon  becomes 
wider  and  convoluted,  and  is  called,  the  proximal  or  first 
convoluted   tubule.     Approaching  the   medulla  they  become 


GEiNERAL   CONSIDERATIONS.  545 

less  convoluted,  then  spiral,  and  enter  the  pyramids  as 
straight  tubes  forming  the  descending  limb  of  the  loop  of 
Henle.  Descending  toward  the  apex  of  the  pyramid,  they 
suddenly  turn,  making  the  loop  of  Henle,  and  ascend  as  a 
straight  tubule  (ascending  limb)  to  the  cortex,  where  they 
again  widen  and  become  convoluted  (distal  or  second  con- 
voluted tubules),  and  arch  into  the  straight  collecting  tube 
which  passes  from  the  cortex  to  the  medulla,  receiving  in  its 
course  through  the  cortex  a  number  of  arches  from  other 
distal  convoluted  tubules.  Toward  the  apex  of  the  pyramid 
several  straight  collecting  tubules  unite  to  form  a  large 
tubule,  finally  ending  in  the  papillary  or  excretory  duct  at 
the  apex  of  the  pyramid.  The  tubules  consist  throughout 
of  a  single  layer  of  cells  on  a  basement  membrane. 

The  character  of  the  cells  varies  in  different  parts  of  the 
tube.  The  capsule  of  Bowman  and  the  adjoining  narrow 
tubule  are  lined  with  squamous  cells.  The  first  or  proximal 
convoluted,  the  spiral  tubules,  and  the  second  or  distal  con- 
voluted tubules  are  lined  with  irregular  columnar  cells ,.  the 
descending  limb  of  Henle's  loop  is  lined  with  simple  squam- 
ous cells ;  the  loop,  the  ascending  limb  and  the  arched  col- 
lecting tubes  are  lined  with  cuboidal  cells.  The  straight 
collecting  tubules  are  lined  with  columnar  cells. 

The  kidneys  are  an  important  unit  of  the  excretory  system 
of  the  body,  the  other  units  being  the  skin,  lungs,  liver  and 
intestines.  There  is  a  close  interaction  among  these  units, 
and  under-  certain  conditions  and  in  a  variable  degree  they 
compensate  each  other.  This  compensatory  action  is  fre- 
quently observed  clinically  between  the  skin  and  the  kidneys, 
and  forms  the  basis  of  treatment  in  those  diseases  of  the  kid- 
ney characterized  by  functional  insufficiency. 

The  excretory  product  of  the  kidneys  is  the  urine.  The 
exact  manner  of  its  elaboration  is  still  unknown,  but  the  lat- 
ter-day theories  may  be  summarized  by  regarding  the  water 
and  its  salts  as  a  product  of  filtration  through  the  glomeruli ; 
the  dissolved  components,  as  urea,  uric  acid,  etc.,  are  the 
products  of  the  activity  of  the  cells  lining  the  uriniferous 
tubules. 

The  filtration  of  water  through  the  glomeruli  is  in  direct 
relation  to  the  pressure  in  the  renal  artery.     A  high  pressure 


546  DISEASES    OF    THE    KIDNEYS. 

is  maintained  in  the  glomeruli,  due  to  the  fact  that  the  ves- 
sels entering-  them  are  of  greater  diameter  than  those  of  exit. 
Filtration,  however,  is  not  the  sole  function  of  the  glomeruli, 
as  their  epithelium  has  a  selective  action  in  removing  some 
of  the  salts  and,  at  the  same  time,  preventing  the  passage  of 
the  serum  albumen  of  the  blood. 

Clinically,  the  theory  of  the  dual  mechanism  of  filtration 
and  secretion  by  the  kidneys  is  supported  by  the  very  com- 
mon observation  that  in  certain  types  of  renal  disease  evi- 
dence of  a  chronic  toxemia  (uremia)  is  present,  even  though 
the  daily  amount  of  water  eliminated  is  normal  or  even 
increased;  the  probable  explanation  being  that  the  ability  of 
the  kidneys  to  filter  the  water  from  the  blood  is  normal,  but 
the  cells  are  unable  to  eliminate  the  toxins.  Under  such  con- 
ditions the  urine  is  pale  in  color  and  of  low  specific  gravity. 
That  the  nen'ous  mechanism  of  the  kidneys  plays  a  role  in 
the  secretion  of  urine  is  certain,  but  to  what  extent  is  un- 
known. As  yet  no  true  excretory  nerve  has  been  discovered, 
but  the  vasodilator  and  vasoconstrictor  functions  have  been 
observed  and  studied  by  physiologists.  Experiments  have 
demonstrated  that  stimulation  of  the  vasodilator  nerves  in- 
creases the  fiow  of  urine,  while  stimulation  of  the  vasocon- 
strictors has  an  opposite  effect.  The  frequent  and  small 
urination  under  the  influence  of  mental  apprehension  is  well 
known  to  the  layman.  Polyuria  in  hysterical  individuals, 
with  normal  kidneys,  is  a  common  occurrence. 

Fresh  normal  urine  is  a  clear  liquid  with  a  specific  gravity 
of  1015  to  1020.  The  color  varies  from  a  pale  yellow  to  a 
reddish  brown,  and  is  due  to  the  presence  of  uribilin,  uro- 
chrome  and  uroerythrin,  all  of  which  are  derived  from  bile 
pigments.  The  normal  reaction  is  acid,  due  to  the  presence 
of  acid  phosphates  of  calcium  and  sodium.  When  neutral  and 
alkaline,  unless  from  decomposition  before  or  after  leaving 
the  body,  the  cause  is  usually  some  metabolic  disturbance, 
or,  as  in  cystitis,  a  disease.  Upon  voiding,  the  temperature 
is  approximately  100°  F.  (37.7°  C).  When,  after  standing, 
it  cools  to  room  temperature,  a  light  cloud  is  observed, 
composed  of  mucus  and  epithelial  cells.  Frequently,  when 
patients  observe  this  cloud  or  turbidity  from  phosphates  they 


GENERAL   CONSIDERATIONS-.  547 

become  frightened  and  l)eHeve  that  they  have  a  serious  dis- 
ease of  the  kidneys. 

The  average  normal  quantity  of  urine  excreted  in  twenty- 
four  hours  is  50  ounces  (1500  mils),  or,  roughly  speaking,  1 
ounce  (30  mils)  per  kidney  per  hour.  The  amount  varies 
with  the  weight  of  the  patient,  the  amount  of  liquid  ingested, 
and  the  amount  of  liquid  lost  through  the  other  organs  of 
excretion,  i.e.,  lungs,  skin,  and  the  gastrointestinal  tract.  For 
example,  profuse  sweating  or  diarrhea  will  cause  a  reduction 
in  the  amount  of  urine,  and  the  imbibing  of  a  large  quantity 
of  liquid  or  the  vasodilation  of  the  renal  capillaries,  secondary 
to  the  constriction  of  vessels  in  the  skin  {e.g.,  effect  of  low 
temperature)  will  increase  the  amount  of  urine.  Reference 
has  already  been  made  to  the  influence  of  the  nervous  system, 
through  the  vasomotor  apparatus. 

It  is  estimated  that  in  1000  mils  (33.8  f§)  of  urine,  solids 
are  present  to  the  extent  of  forty  parts,  composed  of  urea, 
uric  acid,  hippuric  acid,  creatinin,  ammonia  and  various  inor- 
ganic salts,  such  as  chlorides  and  sulphates  of  various  metals. 
The  total  urinary  solids  may  be  estimated  approximately  by 
multiplying  the  last  two  figures  of  the  specific  gravity  by  the 
coefficient  of  Haeser,  2.33.  The  result  expresses  the  total 
solids  in  grams' per  1000  mils  (33.8  ^5)- 

Another  method  is  that  of  Metz,  by  which  the  last  two 
figures,  of  the  specific  gravity  are  multiplied  by  0.00233,  and 
this  product  by  the  total  number  of  cubic  centimeters  of  urine 
excreted  in  the  twenty-four  hours.  The  final  product  will  be 
the  total  weight  of  solids  expressed  in  grams.  Suppose  the 
quantity  of  urine  excreted  in  the  twenty-four  hours  is  1500 
mils  (50  f5),  with  a  specific  gravity  of  1020.  Then  20  X 
0.00233  X  1500  mils  (50  fS)  =69.9  grams  (1083.4  grs.)  of  solids 
in  that  particular  day's  output. 

Of  the  solids,  urea  (CON2H4)  is  the  most  abundant  and, 
perhaps,  the  most  important.  The  amount  excreted  each  day 
varies  from  463  to  617  grains  (30  to  40  Gms.),  representing  an 
amount  of  metabolized  protein  equivalent  to  3  to  4  ounces  (90 
to  120  Gms.)  derived  from  the  protein  of  the  tissues  of  the 
body  and  that  of  the  food  ingested.  The  urea  derived  from 
the  tissue  protein  is  a  fairly  constant  factor,  while  that  derived 
from  the  protein  of  the  food  is  variable,  as  shown  by  the  fact 


548  DISEASES    OF   THE   KIDNEYS. 

that  the  amount  of  urea  varies  with  the  amount  of  protein 
consumed.  Just  what  particular  body  tissue  'or  tissues  un- 
dergo the  protein  metabolism  is  not  known  with  certainty. 
The  absence  of  a  parallelism  between  urea  production  and 
muscle  work  leads  to  the  conclusion  that  there  is  but  little 
protein  metabolism  in  muscle  tissue. 

The  liver  is  probably  the  chief  seat  of  urea  formation.  It 
is  noteworthy  that  in  diseases  of  the  liver  characterized  by 
destruction  of  the  organ,  e.g.,  acute  yellow  atrophy,  abscess, 
etc.,  the  amount  of  urea  excreted  is  diminished,  w^hile  the 
amount  of  ammonium  salts  in  the  urine  is  increased.  Experi- 
mentall^",  when  the  portal  vein  is  anastomosed  wnth  the 
ascending  vena  cava,  thus  excluding  almost  completely  the 
action  of  the  liver  on  the  products  absorbed  from  the  intes- 
tinal canal,  the  output  of  urea  is  diminished  and  the  am- 
monium in  the  urine  is  increased.  The  antecedents  of  urea, 
i.e.,  those  products  from  the  intestinal  canal  from  which  urea 
is  directly  manufactured  in  the  liver,  are  the  carbonate,  car- 
bamate and  lactate  of  ammonia.  Two  molecules  of  water  are 
abstracted  by  the  liver  cells  from  these  products,  forming 
urea,  as  shown  in  this  formula: 

(NH4)2C03  —  2HoO  =  CON0H4. 

The  ammonia  is  derived  from  the  proteins  by  hydrolysis 
and  cleavage.  The  amino-acids,  as  tyrosin,  leucin,  glutamic 
and  aspartic  acids,  diamino-acids  and  bases,  as  lysin,  arginin, 
histidin,  which  are  also  products  of  the  hydrolysis  of  proteins 
during  digestion,  are  capable  of  being  absorbed  as  such  by 
the  epithelial  cells  of  the  villi  and  mucous  membrane,  in  which 
they  undergo  a  cleavage  into  an  NHo  portion  and  an  organic 
portion ;  the  former  is  then  converted  into  ammonia  and  sub- 
sequently into  urea  by  the  liver  cells.  The  intestine  is  not 
the  sole  source  of  the  ammonia  and  the  amino-acids.  There 
is  evidence  that  the  proteins  that  enter  into  the  composition 
of  all  tissues  and  tissue  fluids  are  undergoing  at  all  times  a 
hydrolysis,  under  the  influence  of  enzymes,  whereby  products 
are  produced  similar  to,  if  not  identical  with,  those  produced 
in  tlie  intestine.  These,  after  their  discharge  into  the  blood- 
stream, are  carried  to  the  liver,  where  they  undergo  the  same 
change    as    though    derived    from    the    intestine.      A    certain 


GENERAL   CONSIDERATIONS.  549 

amount  of  urea  arises  from  the  further  metabolism  of  uric 
acid.  It  is  estimated  that  about  one-half  the  uric  acid  formed 
in  man  is  converted  into  urea. 

The  best  and  simplest  method  for  the  quantitative  estima- 
tion of  urea  for  clinical  purposes  is  Knop-Hiifner's  method, 
which  depends  upon  the  decomposition  of  urea  into  carbon 
dioxid,  water  and  nitrogen,  by  means  of  a  solution  of  sodium 
hypobromite  in  an  excess  of  sodium  hydroxid.  The  nitrogen 
liberated  from  a  definite  amount  of  urine  is  measured  volu- 
metrically,  and  from  this  the  corresponding  amount  of  urea 
is  calculated.  The  carbon  dioxid  is  absorbed  by  the  excess 
of  sodium  hydroxid.  The  sodium  hypobromite  solution  may 
be  prepared  as  follows:  Seventy  mils  of  a  30  per  cent,  sodium 
hydroxid  solution  are  mixed  with  180  mils  (6  ozs.)  of  water 
and  5  mils  of  bromin.  The  latter  dissolves  with  the  forma- 
tion of  sodium  bromid  and  sodium  hypobromite. 

2NaOH  +  Bro  =  NaBrO  +  H2O  +  NaBr. 

As  soon  as  the  bromin  has  dissolved,  the  reagent  is  ready 
for  use.  It  should  be  freshly  prepared  every  day,  and  should 
never  be  used  warm.  A  very  convenient  and  economical  way 
is  to  have  the  reagent  made  up  as  two  solutions.  Solution  A 
is  a  25  per  cent,  sodium  hydrate ;  Solution  B  consists  of  bro- 
min 1  part,  potassium  or  sodium  bromid  1  part,  water  8 
parts.  For  the  test,  1  part  of  bromin  solution  is  added  to 
20  parts  of  the  sodium  hydrate  solution.  The  Doremus  or 
the  Doremus-Hinds  ureometer  is  used. 

The  Doremus  ureometer  consists  of  a  bulb  with  an  upright 
graduated  tube  and  a  pipette  graduated  to  hold  1  mil  of  urine. 
The  graduation  on  the  upright  ureometer  reads  in  grams  of 
urea  per  cubic  centimeter  of  urine.  When  a  determination 
is  to  be  made  the  upright  tube  and  about  half  of  the  bulb  are 
filled  with  the  hypobromite  solution.  Care  must  be  taken  to 
exclude  all  air  from  the  tube.  By  means  of  the  pipette  1  mil 
of  urine  is  introduced  into  the  upright  tube  and  a  sufficient 
time  allowed  for  the  evolution  of  gas  to  cease,  usually  about 
ten  to  fifteen  minutes,  at  the  end  of  which  time  the  lower 
meniscus  of  the  solution  is  read  ofif  upon  the  scale.  This 
reading-,  multiplied  by  the  number  of  cubic  milliliters  in  the 
twenty-four-hour   specimen,   will   give    the    quantity   of   urea 


550  DISEASES    OF    THE   KIDNEYS. 

excreted  in  twenty-four  hours  expressed  in  grams.  In 
studying  the  urea  excretion  it  is  necessary  to  estimate  the 
quantity  in  a  twenty-four-hour  collection  of  urine,  and  a 
record  of  the  quantity  and  kinds  of  food  eaten  should  be  kept 
during  the  collection  of  the  specimen. 

Uric  Acid  (C5H4N4O3)  is  a  normal  constituent  of  the. 
urine,  varying  in  quantity  from  2  to  15  grains  (0.13  to  0.9  Gm.) 
in  twenty-four  hours.  It  probably  does  not  exist  in  a  free 
state  in  the  urine,  but  is  combined  with  sodium  and  potassium 
in  the  form  of  a  quadriurate.  The  urates,  when  in  excess,  are 
frequently  deposited  from  the  urine  as  a  brick-red  sediment, 
the  color  being  due  to  their  combination  with  the  coloring 
matter  uroerythrin.  When  pure,  uric  acid  crystallizes  in  the 
rhombic  form,  though  it  may  assume  a  variety  of  other  forms. 
It  is  a  cleavage  product.  Nuclein,  a  constituent  of  the  nuclei 
of  all  cells,  yields  nucleic  acid  during  metabolism,  and  from 
the  latter  uric  acid  is  derived.  Nucleic  acid,  when  decom- 
posed, yields  a  series  of  bases,  such  as  xanthin,  hypoxanthin, 
adenin,  guanin,  etc.,  which,  because  of  the  fact  that  they  can 
also  be  obtained  from  a  synthesized  body  called  purin,  are 
called  collectively  the  purin  bases.  There  is  a  close  connec- 
tion between  these  bases  and  uric  acid.  It  is  likely  that  uric 
acid  is  derived  from  one  of  them,  probably  hypoxanthin. 
Uric  acid  in  the  body  has  an  endogenous  and  exogenous 
origin,  i.e.,  it  is  derived  from  the  nuclein  of  the  body  cells 
and  from  the  cells  of  ingested  animal  food.  In  a  disease  char- 
acterized by  a  very  great  increase  in  the  number  of  leuco- 
cytes, as  in  leukemia,  uric  acid  excretion  is  increased. 

The  Murexid  Test.  Add  a  drop  of  nitric  acid  to  a  small 
quantity  of  urine  in  a  porcelain  dish  and  evaporate  to  dryness. 
After  cooling,  allow  a  drop  or  two  of  ammonia  water  to  come 
in  contact  with  the  residue,  and  in  the  presence  of  uric  acid 
or  urates,  a  bright  blue-violet  color  will  be  produced. 

Schiff's  Test.  Add  a  drop  of  nitric  acid  to  a  small  quantity 
of  urine  and  evaporate  to  dryness.  Dissolve  the  residue  in  a 
test-tube  with  the  aid  of  a  solution  of  sodium  carbonate. 
Moisten  some  filter  paper  with  a  10  per  cent,  solution  of  sil- 
ver nitrate.  Allow  a  few  drops  of  the  solution  in  sodium  car- 
bonate to  fall  in  the  center  of  the  moistened  filter  paper.  If 
uric  acid  is  present,  the  silver  nitrate  will  be  reduced  to  black 
metallic  silver. 


CREATININ.  551 

Hippuric  Acid,  in  combination  with  sodium  and  potassium, 
is  usually  present  in  the  urine  of  man  to  the  extent  of  11 
grains  (0.7  Gm.).  This  amount  is  increased  when  asparagus, 
plums,  cranberries,  apples,  grapes,  etc.,  are  eaten,  or  benzoic 
or  cinnamic  acids  are  administered.  There  is  evidence  that 
hippuric  acid  is  formed  in  the  kidney  from  benzoic  acid.  The 
former  crystallizes  as  rhombic  prisms,  resembling  somewhat 
the  "coffin-lid"  crystals  of  triple  phosphates.  Hippuric  acid 
crystals  are  distinguished  by  the  fact  that  they  are  pre- 
cipitated in  acid  urine  only,  and  also  by  their  not  dissolving 
on  the  addition  of  acetic  acid.  The  phosphates,  on  the  con- 
trary, are  precipitated  only  in  neutral  or  alkaline  urine,  and 
are  readily  soluble  in  dilute  acetic  acid. 

Creatinin,  a  crystalline  nitrogenous  compound,  is  excreted 
daily  to  the  extent  of  15.4  grains  (0.9  Gm.).  It  is  the  end 
product  of  metabolism  of  muscle  albumen,  and  its  source  is 
the  creatin  of  the  muscles  of  the  body  and  of  the  muscles 
of  animals  eaten  as  food.  It  is  distinguished  in  the  urine  by 
its  union  with  zinc  chloride,  with  which  it  forms  an  insolu- 
ble compound,  appearing  under  the  miscroscope  as  minute 
needles,  arranged  as  balls  and  rosettes.  Creatinin  reduces 
alkaline  copper  solutions,  and  therefore  affects,  in  a  slight 
degree,  the  accuracy  of  the  quantitative  sugar  estimations 
which  depend  upon  the  reducing  power  of  sugar-containing 
urine. 

Weyl's  Test.  Add  a  few  drops  of  a  freshly  made,  very 
dilute  aqueous  solution  of  sodium  nitroprusside  and  a  few 
drops  of  dilute  sodium  hydrate  solution  to  about  10  mils  (2.7 
fo')  of  urine  in  a  test-tube.  In  the  presence  of  creatinin  a  ruby 
red  color  appears  which  changes  after  a  short  time  to  an  in- 
tense yellow.  If  this  solution  be  heated  with  a  little  glacial 
acetic  acid,  the  yellow  will  change  to  green,  and  finally  to  blue. 
Acetone  gives  a  similar  reaction,  but  on  the  addition  of  acetic 
acid  changes  to  a  purplish  red  instead!  of  green.  If  the  urine 
be  heated  previous  to  the  application  of  this  test,  the  acetone 
will  be  driven  off. 

Jajfe's  Test.  Add  a  few  drops  of  a  saturated  watery  solu- 
tion of  picric  acid  and  a  few  drops  of  10  per  cent,  sodium 
hydrate  solution  to  some  urine  in  a  test-tube.  If  creatinin  is 
present  a  red  color  appears  immediately,  which  increases  in 


552  DISEASES    OF    THE    KIDXEYS. 

intensity  and  remains  permanent  for  a  long  time.  If  glacial 
acetic  acid  is  added,  the  color  becomes  yellow.  Acetone  gives 
a  reddish  yellow  color  of  less  intensity  than  that  produced  by 
creatinin.  Glucose,  if  present,  gives  a  red  color,  especially  if 
the  mixture  be  warmed. 

Inorganic  Salts.  Sodium  and  potassium  phosphates, 
known  as  the  alkaline  phosphates,  are  found  in  the  urine,  the 
total  quantit}^  being  about  61.7  grains  (4  Gms.).  Calcium  and 
magnesium  phosphates,  known  as  the  earthy  phosphates,  are 
present  to  the  extent  of  15.4  grains  (1  Gm.).  .  They  are  held 
in  solution  in  the  urine  by  its  acid  constituents.  If  the  urine 
be  rendered  alkaline,  they  are  precipitated.  Sodium  and 
potassium  sulphates  are  also  present  to  the  extent  of  about 
30.9  grains  (2  Gms.).  The  phosphoric  and  sulphuric  acids, 
which  are  combined  with  these  bases,  enter  the  body,  for  the 
most  part,  in  the  foods,  though  there  is  evidence  that  they 
also  arise  by  oxidation  in  consequence  of  the  metabolism  of 
proteins  which  contain  phosphorus  and  sulphur. 

Sodium  chlorid,  the  most  abundant  of  the  inorganic  salts, 
is  derived  mainly  from  the  food,  and  is  excreted  to  the  extent 
of  about  231.5  grains  (15  Gms.)  in  twent3-four  hours. 

As  previously  stated,  when  the  urine  becomes  alkaline,  the 
phosphates  are  precipitated  and  appear  as  coffin-lid  crystals 
of  ammonio-magnesium  phosphate,  needle-like  crystals  of  cal- 
cium phosphate,  or  as  amorphous  phosphates,  i.e.,  fine  gran- 
ules. The  phosphoric  sediments  are  readily  distinguished  by 
the  alkaline  reaction  of  the  urine,  and  by  their  insolubility  by 
heat  (by  which  the  urates  are  dissolved)  and  their  solubility 
in  acetic  acid.  This  sediment  acquires  importance  only  when 
formed  within  the  bladder  as  a  result  of  infection. 

Anomalies  and  Malformations.  The  absence  or  malde- 
velopment  of  one  kidney  is  not  uncommon,  and  its  discovery 
is  usually  accidental.  As  a  rule,  malformation  of  one  or  both 
kidneys  is  of  no  great  importance.  The  absence  of  one  kid- 
ney, however,  may  become  of  the  utmost  importance  when  a 
renal  affection  requiring  operation  occurs.  The  sudden  aboli- 
tion of  function  of  the  single  organ,  as,  for  instance,  from 
occlusion  of  the  renal  pelvis  or  ureter  by  a  calculus,  may  cause 
death.  The  occurrence  of  renal  colic,  with  complete  anuria 
lasting  for   some   time,   may   suggest  the   correct  diagnosis, 


DISPLACEMENTS    OF    THE    KIDNEY.  553 

which  is  confirmed  1)y  the  finding  of  but  one  ureteral  orifice 
on  C3^stoscopic  examination  of  the  bladder.  Very  rarely  two 
ureteral  orifices  are  found  in  the  bladder  when  there  is  but 
one  kidney. 

More  frequently  the  kidneys  are  fused  at  either  the  upper 
or  lower  poles  forming  the  horseshoe  kidney  (Ren  Arcn- 
atiis).  Usually  the  lower  poles  are  fused,  while  the  upper 
poles  are  free  and  lie  to  the  right  and  left  of  the  vertebral, 
column.  Very  rarely  the  kidneys  may  be  fused  throughout 
their  length,  and  both  together  may  lie  entirely  to  the  right 
or  left  of  the  spinal  column.  Such  anomaly  may  lead  to 
errors  in  diagnosis,  as  the  fused  kidneys  may  be  mistaken  for 
a  tumor.  Their  removal  would,  of  course,  lead  to  the  death 
of  the  patient.  The  existence  of  a  developmental  error,  such 
as  absence  or  maldevelopment  of  one  or  both  kidneys  may  be 
suspected  when  there  is  some  anomaly  of  the  sexual  organs, 
as  the  two  are  often  associated,  and  may  be  accurately  diag- 
nosed by  radiograms. 

DISPLACEMENTS  OF  THE  KIDNEY. 

Either  one  or  both  kidneys  may  be  displaced.  The  ptosis 
may  be  congenital  or  acquired.  The  displaced  organ,  or  or- 
g-ans,  may  be  freely  movable  or  fixed  in  an  abnormal  location. 
When  the  displacement  is  congenital  the  left  kidney  is  more 
likely  to  be  afifected,  and  is  said  to  be  more  commonly  found 
in  men  than  in  women. 

Acquired  displacement  of  the  kidneys  is  more  common  in 
the  female,  is  usually  unilateral,  the  right  being  more  fre- 
quently involved.  As  a  rule,  the  organ  is  freely  movable. 
This  mobility  may  vary  from  a  slight  degree  that  permits 
easy  palpation  of  the  lower  pole  during  inspiration,  to  a 
degree  that  permits  the  organ  to  be  moved  by  the  palpating 
hand  in  various  directions  in  the  abdomen.  It  is  possible  to 
classify  movable  kidney  into  three  groups  according  to  the 
degree  of  mobility.  In  Group  A,  The  Palpable  Kidney,  one 
is,  just  able  to  feel  the  lower  pole  below  the  edge  of  the  ribs 
during  deep  inspiration  only.  When  the  entire  organ  descends 
so  low  that  one  may  dip  down  between  the  edge  of  the  ribs 
and  the  upper  pole  of  the  kidney,  it  may  be  called  a  Movable 


554  DISEASES    OF   THE   KIDNEYS. 

Kidney,  and  is  placed  in  the  second  group.  In  the  third 
group,  Floating  Kidney,  the  organ  is  so  freely  movable  that 
it  ma}'  be  felt  just  above  Poupart's  ligament,  or  in  the  mid- 
line of  the  bod}-.  It  may  even  be  pushed  to  the  opposite  side 
of  the  spinal  column  b}-  the  palpating  hands. 

]\Iobile  kidney  is  very  common,  and,  as  usually  encount- 
ered, belongs  to  Group  A  or  Group  B.  Examples  of  the  third 
group  are  much  more  rarely  observed. 

The  most  important  etiologic  factor  is  sex.  The  relation 
of  incidence  in  women  to  men  is  given  by  Dietle  as  100  to  1. 
This  corresponds  to  our  own  experience,  in  which  men  have 
been  found  to  be  very  rarely  affected.  While  it  may  occur 
at  any  age,  it  is  most  commonly  found  in  adults  between  the 
ages  of  30  and  60  years.  Relaxation  of  the  abdominal  wall, 
such  as  may  follow  child  bearing,  and  overdistention  from 
fluid  or  tumors,  causing  changes  in  the  intra-abdominal  pres- 
sure, is  a  factor.  The  body  form  is  an  important  etiologic 
factor  in  movable  kidne}*.  The  space  normally  occupied  by 
the  kidneys,  kidney  niches  or  depressions,  may  be  flatter  than 
normal,  and  on  the  right  side,  especially  in  women,  more  open 
below,  so  that  dislocation  more  readily  takes  place.  Such  a 
condition  of  affairs  is  observed  in  Avomen  of  slender  build  with 
narrow  thorax  and  flattened  abdomen. 

Tight  lacing  ma}-  cause  a  dislocation  of  the  kidney  by 
compression  of  the  superior  half  of  the  abdomen,  forcing 
downward  the  viscera;  the  disturbance  of  circulation  result- 
ing therefrom  favors  relaxation  of  the  attachments  of  the 
kidneys,  still  further  favoring  their  displacement. 

Extreme  emaciation  ^vith  loss  of  fat  from  the  renal  capsule 
may  sometimes  permit  of  ver}^  greatly  increased  renal  mobil- 
ity. A  predisposition  to  movable  kidney  exists  in  certain 
individuals,  and  other  factors  may  be  at  work,  as  renal  dis- 
placement is  frequently  not  observed  in  emaciation.  The 
right  kidne}-  is  most  usually  affected.  Rarely  are  both  kid- 
neys dislocated,  and  still  more  rarely  the  left  alone.  The  fact 
that  the  right  kidney  is  more  often  affected  than  the  left  is 
probably  due  to  the  difference  between  the  peritoneal  and 
connective  tissue  attachments  on  the  two  sides  of  the  body. 
The  anterior  portion  of  the  renal  fascia  is  reinforced  on  the 
left  side  by  a  triple  layer  of  peritoneum.    The  colon  probably 


DISPLACEMENTS   OF   THE   KIDNEY.  555 

lends  some  support  to  the  left  kidney,  and  ptosis  of  the  splenic 
flexure  is  extremely  rare.  The  hepatic  flexure  of  the  colon, 
on  the  other  hand,  is  very  frequently  ptosed,  and  normally 
there  is  a  greater  downward  pull  exerted  by  the  cecum,  be- 
cause of  the  weight  of  fecal  material,  which  is  so  commonly 
retained  there.  The  left  renal  artery  is  shorter  than  the  right, 
and  is  rather  closely  attached  to  the  pancreas  by  cellular 
tissue. 

Distortion  of  the  vertebral  column,  tumors  in  the  region 
of  the  kidney,  or  the  weight  of  a  large  pleural  effusion  may 
displace  the  kidney  downward.  Traumatism  may  occasion- 
ally play  a  role.  Very  commonly,  movable  kidney  is  asso- 
ciated with  gastroenteroptosis.  It  may  be  present  as  a  part 
of  the  general  ptosis  of  the  abdominal  viscera  in  Glenard's 
disease. 

In  the  vast  majority  of  instances  symptoms  are  absent,  the 
condition  being  discovered  in  the  course  of  a  routine  physical 
examination.  When  thus  found,  judgment  should  be  exer- 
cised in  determining  its  relative  importance  in  the  clinical 
picture  presented  by  the  patient,  who  is  often  neurasthenic, 
and  sometimes  hysteric.  Unless  it  is  evident  that  the  mobile 
kidney  is  producing  symptoms,  it  is  best  to  keep  the  patient 
ignorant  of  its  existence,  more  especially  in  the  case  of  a 
hysterical  or  neurasthenic  subject.  Not  infrequently  individ- 
uals are  encountered  who  have  become  hypochondriacal  after 
being  told  that  the  kidney  is  movable. 

As  has  been  stated,  movable  kidney  usually  is  associated 
with  ptosis  of  the  colon  or  stomach.  Symptoms,  such  as  con- 
stipation, recurring  headaches,  with  or  without  nausea  and 
vomiting,  due  to  autointoxication  from  fecal  stasis ;  a  sense 
of  weight  in  the  region  of  the  stomach  after  eating  or  drink- 
ing, are  due  to  the  ptosed  stomach  and  colon,  and  have  no 
relationship  to  the  mobility  of  the  kidney.  Symptoms  directly 
referable  to  the  movable  kidney  are  sometimes  noted,  and 
consist  most  commonly  in  a  sense  of  discomfort  in  the  right 
or  left  loin,  as  the  case  may  be,  and  a  dull  aching  in  these 
regions  and  in  the  flanks  after  standing,  lifting,  straining  or 
walking. 

Patients,  in  rubbing  the  abdomen  to  relieve  the  aching, 
sometimes  feel  the  mass  which  they  suppose  is  a  tumor,  and 


556  DISEASES   OF   THE   KIDNEYS. 

are  thereby  led  to  consult  a  physician.  Usually  the  aching 
and  discomfort  disappear  when  the  recumbent  posture  is 
assumed,  and  it  is  not  uncommon  to  note  that  these  symp- 
toms are  complained  of  especially  toward  the  end  of  the  day. 
Cases  have  been  reported  in  which  jaundice  occurred,  due  to 
pressure  by  the  kidney  on  the  gall-ducts.  If  this  does  occur, 
it  is  extremely  rare.  It  is  more  probable  that  the  jaundice  is 
coincidental,  i.e.,  due  to  a  cause  entirely  dissociated  from  the 
mobile  kidney. 

When  the  mobility  of  the  kidney  is  considerable  a  Dietl's 
crisis  may  occur,  due  to  a  twisting  or  kinking  of  the  ureter  or 
renal  vessels.  Sudden,  sharp  pain  occurs  in  the  renal  region 
of  the  affected  side,  with  chill,  fever,  nausea  and  vomiting. 
The  urine  becomes  diminished  in  quantity,  is  high  colored, 
and  may  contain  albumen  and  blood.  Urates  and  calcium 
oxalate  crystals  are  frequently  found  in  the  urine.  Prostra- 
tion is  sometimes  very  pronounced,  and  the  pain  may  be  as 
severe  as  that  of  renal  or  ureteral  calculus.  The  abdominal 
muscles  become  tense  and  abdominal  palpation  painful.  The 
rigid  abdominal  muscles  may  preclude  the  possibility  of  feel- 
ing the  kidney.  It  is  sometimes  impossible  to  differentiate 
between  a  Dietl's  crisis  and  renal  or  ureteral  calculus.  In 
some  cases  a  mass  may  be  felt  which  is  very  tender  on  pres- 
sure, and  which  gradually  increases  in  size  during  the  attack, 
due  to  increasing  hydronephrosis.  As  the  attack  subsides  the 
flow  of  urine  increases  and  may  suddenly  become  quite  pro- 
fuse. The  pain  may  disappear  rapidly  or  gradually,  and  may 
be  followed  by  a  sense  of  soreness  in  the  renal  region.  The 
rigid  abdominal  muscles  gradually  relax,  and  palpation  then 
reveals  the  displaced  kidney,  which  usually  is  tender  on  pres- 
sure for  several  subsequent  days.  The  attack  may  last  from 
a  few  hours  to  a  day,  or  more,,  and  may  recur  at  irregular 
intervals. 

As  a  rule,  the  diagnosis  is  easily  made  by  palpating  a 
movable  mass  which  has  the  shape  and  consistence  of  the 
kidney.  It  is  felt  to  descend  deeply  from  beneath  the  ribs, 
and  usually  moves  up  and  down  with  respiration.  It  may 
be  painless  on  pressure,  or  when  compressed  between  the  pal- 
pating hands  may  give  rise  to  a  dull,  sickening  ache.  In 
palpating  for  a  movable  kidney  the  patient  should  lie,  prefer- 


DISPLACEMENTS    OF    THE    KIDNEY.  557 

ably,  on  the  back  with  the  knees  flexed  so  as  to  secure  the 
maximum  relaxation  of  the  abdominal  muscles.  In  palpating 
for  the  right  kidney  the  left  hand  should  be  placed  against 
the  patient's  back  just  below  the  last  rib  on  the  right  side, 
while  the  right  hand  is  placed  opposite  on  the  abdomen.  A 
deep  inspiration  will  drive  the  kidney  downward  between  the 
palpating  hands.  If  this  fails,  the  patient  should  sit  up  for 
a  few  minutes  breathing  deeply  or  arise  and  walk  about  the 
room,  after  which  an  examination  will  be  quite  successful.  It 
is  frequently  recommended  that  the  patient  be  examined 
while  in  the  erect,  or  in  a  stooping  posture,  but,  as  a  rule,  the 
abdominal  muscles  are  thus  rendered  too  rigid  to  permit  of 
a  satisfactory  examination.  As  stated,  the  diagnosis  during 
a  Dietl's  crisis  may  be  very  difficult,  or  even  impossible,  if 
the  kidney  cannot  be  palpated  and  the  patient  is  seen  for  the 
first  time.  The  condition  may  be  confounded  with  a  con- 
stricted hepatic  lobe  (Schniirlappen),  particularly  the  tongue- 
shaped  prolonged  anterior  lobe,  or  with  a  thickened  and 
enlarged  gall-bladder  frequently  found  after  repeated  attacks 
of  gall-stone  colic.  There  is  a  notch  between  such  a  lobe  and 
the  head  of  the  gall-bladder  which  closely  simulates  the  hilus 
of  the  kidney ;  the  lobe  can  often  be  turned  over  so  that  it 
apparently  occupies  the  position  of  the  kidney ;  and  the  symp- 
toms produced  by  gall-stones  are  quite  similar  to  the  symp- 
toms of  movable  kidney.  A  mistake  in  diagnosis  is,  there- 
fore, easy  to  make.  By  carefully  examining  the  suspected 
region  by  palpation  and  percussion,  with  the  patient  lying  on 
the  left  side,  the  relation  of  the  mass  to  the  liver  can  usually 
be  determined. 

TREATMENT. 

Many  cases  require  no  direct  treatment.  This  is  partic- 
ularly true  of  that  large  class  of  cases  without  symptoms,  the 
mobility  of  the  kidney  having  been  discovered  during  the 
course  of  a  routine  physical  examination.  In  many  instances, 
the  patient,  usually  a  woman,  seeks  relief  from  symptoms 
denoting  neurasthenia.  Such  a  patient  is  likely  to  be  under 
weight,  with  a  long,  narrow  thorax,  with  an  acute  subcostal 
angle,  a  costal  margin  that  dips  down  laterally,  almost  touch- 
ing the  iliac  crests,   and  general  muscular  relaxation,   espe- 


558  DISEASES    OF    THE    KIDNEYS. 

cially  well  marked  in  the  abdominal  muscles.  Formerly 
these  symptoms,  i.e.,  of  neurasthenia,  were  erroneously  attrib- 
uted to  the  renal  mobility.  Today  it  is  generally  recognized 
that  the  latter  may  be  only  a  detail  of  the  general  symptom 
complex  presented  by  the  patient,  and  is  only  occasionally 
the  real  factor  of  neurasthenia.  The  treatment  is,  therefore, 
directed  to  the  whole  body,  and  is  based  upon  a  study  of  the 
particular  individual,  a  stud}^  that  includes  an  estimate  of  the 
digestion  and  assimilation  of  food,  intestinal  toxemia,  and 
similar  details. 

To  as  great  an  extent  as  possible  the  patient  must  be 
relieved  of  responsibility,  so  as  to  avoid  further  fatigue  of  the 
nervous  system.  If  the  neurasthenia  be  of  sufficient  degree, 
a  complete  rest  cure  is  necessary.  Ordinarily  the  patient  is 
directed  to  retire  at  8  p.m.  or  9  p.m.  and  to  remain  in  bed  until 
8  A.M.  or  9  A.M.  Upon  arising  a  salt  water  sponge  bath  should 
be  taken.  For  this  purpose  an  earthenware  vessel  containing 
a  saturated  solution  of  rock  salt  is  kept  in  the  bathroom. 
AA^ith  this  solution  the  body  should  be  sponged  quickly,  and 
this  followed  by  brisk  rubbing  with  a  coarse  Turkish  towel 
For  one  unaccustomed  to  cold  water  the  sponge  baths  may 
be  taken  at  a  temperature  of  98°  F.  (36.6°  C.)  gradually,  day 
by  day,  reducing  the  temperature  of  the  water  until  it  is 
the  same  as  that  of  the  room.  If  burning  or  itching  of  the 
skin  follows  the  use  of  the  brine,  it  may  be  diluted,  or  the 
body  ma}^  be  sponged  with  clear  water  after  the  brine  sponge 
bath. 

Then  follows  breakfast,  which  should  consist  of  fresh  fruit, 
a  cooked  cereal,  one  or  two  poached  or  soft-boiled  eggs,  and 
bread  or  rolls  with  butter.  Milk  or  cocoa  is  preferable  to  tea 
or  coffee  because  of  their  high  nutritive  value.  Dinner  should 
be  eaten  in  the  middle  of  the  day,  and  should  consist  of  soup, 
meat  and  vegetables.  The  evening  meal  should  be  light. 
Meat  should  be  eaten  but  once  daily. 

If  the  examination  of  the  stomach  contents  obtained  one 
hour  after  the  ingestion  of  a  test  breakfast  reveals  a  hypo- 
chlorhydria,  hydrochloric  acid,  U.  S.  P.,  in  10-  to  20-  drop  (0.62 
to  1.2  mils)  doses  in  water,  should  be  given  after  meals.  Pep- 
sin should  be  supplied  when  a  test  shows  it  to  be  absent,  an 


DISPLACEMENTS    OF    THE    KIDNEY.  559 

event  which  is  extremely  rare.  The  feces  must  be  examined 
at  intervals  to  detect  the  presence  of  carbohydrate  fermenta- 
tion or  protein  decomposition,  and  if  either  be  found  the  diet- 
ary must  be  modified  accordingly.  In  some  instances  the 
administration  of  pancreatin  and  diastase  has  seemed  to  aid 
the  dig'estion.  The  importance  of  thorough  mastication  in  the 
preparation  of  the  food  for  the  stomach  must  be  remembered, 
and  if  molars  are  absent,  an  efficient  artificial  grinding  surface 
should  be  supplied  by  a  dentist. 

As  a  part  of  the  general  muscular  relaxation,  atony  of  the 
muscular  coat  of  the  colon,  especially  of  the  cecum  and 
ascending  colon  is  present.  This  permits  of  fecal  stasis,  dur- 
ing which  as  a  result  of  bacterial  activity,  decomposition  of 
proteins  or  carbohydrates  with  the  formation  and  absorption 
of  toxic  substances  occurs.  A  study  hy  means  of  the  X-rays 
will,  of  course,  establish  beyond  question  the  diagnosis  of 
fecal  stasis.  Clinically,  this  may  be  determined  as  follows : 
The  bowels  are  permitted  to  move  spontaneously  at  the  usual 
time  in  the  morning  after  breakfast;  or,  if  necessary,  an 
enema  of  1  pint  (473.1  mils)  of  normal  salt  solution  is  given, 
so  as  to  empty  the  rectum  and  sigmoid  flexure.  Immediately 
after  the  bowels  move  a  soft  rubber  rectal  tube  is  inserted  6 
to  8  inches  (15.2  to  20.3  cm.)  into  the  rectum,  and  3  pints  (1.5 
1.)  of  warm  normal  salt  solution  (a  teaspoonful  (3.7  mils)  of 
table  salt  to  1  pint  (473.1  mils)  of  water)  is  allowed  to  flow 
slowly  into  the  rectum  while  the  patient  lies  on  the  rigiit 
side.  Sometimes,  owing  to  an  accumulation  of  gas  in  the 
sigmoid  or  rectum,  or  to  a  failure  of  the  solution  to  pass 
into  the  descending  colon,  the  patient  experiences  a  strong 
impulse  to  evacuate  the  water,  in  which  event  the  inflow 
should  be  stopped  and  the  abdomen  rubbed,  with  deep  pres- 
sure, from  below  upward  to  the  costal  border  on  the  left 
side.  In  a  few  seconds  the  spasm  disappears,  and  more  of 
the  solution  is  allowed  to  flow  in.  It  may  be  necessary  to 
resort  to  the  manual  dispersion  of  the  liquid  in  the  colon  sev- 
eral times  before  3  pints  (1.5  1.)  are  finally  introduced.  When 
all  the  salt  solution  has  entered  the  colon,  the  rectal  tube  is 
withdrawn ;  the  patient  then  lies  on  the  back  and  the  abdomen 
is  rubbed  from  below  upward  to  the  costal  border  on  the  left 
side,  from  left  to  right  across  the  abdomen  along  the  usual 


560  DISEASES    OF   THE   KIDNEYS. 

position  of  the  transverse  colon,  and  from  the  costal  margin 
downward  on  the  right  side.  In  this  manner  the  solution  is 
driven  into  the  cecum,  and  its  presence  there  is  determined 
by  a  splashing  sound  on  succussion  over  the  right  lower 
abdominal  quadrant.  The  water  should  then  be  evacuated 
into  a  jar,  so  that  the  amount  of  fecal  material  returned  with 
the  salt  solution  may  be  estimated.  More  than  4  ounces  (118.4 
mils)  of  feces,  by  volume,  should  be  regarded  as  evidence  of 
fecal  retention,  and  should  be  treated  by  colonic  lavage,  the 
technic  of  which  is  identical  with  that  of  the  diagnostic  lavage 
just  described. 

The  presence  of  indican  in  the  urine^  due  to  the  decom- 
position of  proteins,  is  very  commonly  associated  with  fecal 
stasis,  and  often  indicates  the  success  or  failure  of  efforts  to 
empty  the  colon  or  cecum.  Indican  may  be  tested  for  very 
easily  and  quickly  as  follows :  To  3  or  4  mils  (48.6  or  64.8  m.) 
of  urine  add  1  drop  of  1  per  cent,  solution  of  potassium 
chlorate,  2  or  3  mils  (32.5  or  48.6  m.)  of  chloroform,  and  as 
much  strong  hydrochloric  acid  as  urine.  Thoroughly  mix  by 
pouring  from  one  test-tube  to  another  eight  or  ten  times. 
The  appearance  of  a  blue  color  in  the  chloroform,  which  falls 
to  the  bottom  of  the  tube,  denotes  the  presence  of  indican.  A 
rough  idea  of  the  quantity  may  be  formed  by  the  depth  of 
color. 

The  lack  of  muscular  tone  should  be  treated  by  general 
massage,  which  is  later  replaced  by  resisted  movements  and 
active  exercise,  especial  attention  being  directed  to  the  ab- 
dominal muscles.    The  following  exercises  are  recommended : 

(a)  Lying  flat  on  the  back,  body  in  a  straight  line,  toes 
turned  upward  and  arms  extended  by  the  sides,  the  head  is 
slowly  raised,  bending  the  neck  until  the  chin  touches  the 
chest.  Then  the  trunk  is  slowly  raised  until  "the  body  is 
brought  to  a  sitting  posture.  While  this  is  being  accom- 
plished the  heels  must  remain  in  contact  with  the  floor,  the 
knees  kept  straight  and  stifif,  and  the  hands  allowed  to  slide 
along  the  thighs.  The  body  is  then  slowly  lowered  to  recum- 
bency. 

(b)  Lying  flat  on  the  back  with  the  body  in  a  straight 
line,  toes  turned  upward  and  arms  extended  by  the  sides,  the 
legs  are  raised  slowly  from  the  hips,  keeping  the  knees  stiff, 


ANOMALIES    OF    URINARY    SECRETION.  561 

until  at  rig"ht  angles  to  the  trunk.  They  are  then  slowly  low- 
ered to  the  floor. 

These  exercises  must  be  practised  cautiously.  It  may  be 
necessary  to  advise  the  patient  to  raise  the  body  a  few  inches 
only  from  the  floor,  and  not  to  attempt  to  assume  the  sitting 
posture,  because  of  the'  possibility  of  straining  the  muscles  or 
producing  a  hernia.     Supervision  is  therefore  necessary. 

Where  the  abdominal  muscles  are  extremely  atonic,  and 
in  cases  of  mobile  kidney  secondary  to  multiple  pregnancies, 
a  binder  with  a  pad  is  necessary.  The  binder  may  be  of  silk 
or  cotton,  supplied  with  perineal  straps  to  prevent  it  from 
slipping  upward,  and  should  come  well  down  on  the  hips.  A 
pad  may  be  used,  and  must  be  so  placed  as  to  make  pressure 
upward  and  backward  and  toward  the  right,  in  order  to  push 
the  kidney  towards  its  normal  position.  The  pad  should  be 
soft  but  firm,  about  3  inches  (7.6  cm.)  long  and  2  or  2^  inches 
(5.08  or  6.3  cm.)  wide.  It  is  so  placed  that  the  upper  border 
faces  upward  and  towards  the  right,  lying  a  little  below  the 
line  passing  from  the  umbilicus  to  the  anterior-superior  spine 
of  the  ilium.  The  belt  should  always  be  applied  while  the 
patient  is  in  the  recumbent'  posture,  and  the  kidney  is  in  place. 
It  should  never  be  applied  while  the  patient  is  in  the  erect 
posture,  as  the  pad  may  then  be  above  the  kidney,  and  by 
pressing  downward,  thus  aggravate  the  condition.  The  wear- 
ing of  a  binder  should  be  looked  upon  as  a  temporary  meas- 
ure, to  be  used  until  the  emaciation  is  overcome,  or  until  the 
abdominal  muscles  become  strengthened  by  exercise.  In  ex- 
treme cases  it  is  necessary  to  take  up  the  redundancy  in  the 
overstretched  abdominal  muscles  by  surgical  means. 

The  anchoring  of  the  kidney  surgically  should  never  be 
done  excepting  in  those  cases  of  floating  kidney  that  give  rise 
to  Dietl's  crisis,  or  show  evidence  of  congestion  due  to  twist- 
ing of  the  renal  vessels ;  also  when  other  measures  have  failed 
to  relieve  cases  in  which  neurasthenia  can  be  definitely 
ascribed  to  the  movable  kidney. 

ANOMALIES  OF  URINARY  SECRETION. 

Anuria.  Total  suppression  of  urine  occurs  in  intense  con- 
gestion  of  the   kidneys,   which   may   be   active,   as   in   acute 


562  DISEASES    OF    THE    KIDNEYS. 

nephritis  due  to  infections,  fevers,  poisoning  with  phosphorus, 
arsenic,  mercury  and  lead ;  or  passive,  as  in  the  cyanotic  kid- 
ney, which  occurs  in  cardiac  dilatation  and  late  in  the  course 
of  myocardial  degeneration.  The  anuria  may  be  mechanical, 
as  the  result  of  blocking  of  the  ureter  by  a  calculus,  blood- 
clot  or  a  thick  mass  of  pus,  or  by  the  compression  of  the 
ureters  by  new  growths  in  the  abdominal  cavity.  It  may 
follow  ureteral  catheterization,  and  is  sometimes  seen  in 
hysteria. 

A  patient  may  live  for  days,  and  even  for  one  or  two 
weeks,  with  complete  suppression  of  urine,  during  which  time 
consciousness  may  be  retained  and  the  mind  remain  clear. 
Nausea  and  occasional  vomiting  may  occur.  Convulsions  may 
not  occur.  In  a  fatal  case  of  bichlorid  of  mercury  poisoning, 
observed  by  the  authors,  complete  suppression  of  urine 
existed  for  a  week^  during  which  time  there  were  no  symp- 
toms of  uremia.  It  is  necessary  to  differentiate  between 
anuria  or  urinary  suppression  and  retention.  In  any  disease 
characterized  by  extreme  adynamia,  as  in  the  typhoid  state, 
or  when  unconsciousness  occurs,  or  when  opium  is  given,  the 
kidneys  may  secrete  a  greatly  diminished  quantity  of  urine 
which  is  retained  in  the  bladder.  In  hospital  practice  it  is 
not  uncommon  to  find,  on  admission,  that  the  bladder  of  the 
patient  who  had  passed  no  urine  for  a  day  or  two  contains 
16  to  40  (473  to  1183  mils),  or  even  50  ounces  (1478  mils)  of 
urine.  It  is,  therefore,  necessary,  in  the  case  of  all  patients 
who  are  thought  to  be  anuric,  to  palpate  in  the  suprapubic 
region  for  a  distended  bladder;  and,  if  necessary,  to  resort  to 
catheterization  to  establish  diagnosis.  Treatment  depends 
upon  the  nature  of  the  underlying  cause.  Thus,  when  the 
anuria  is  due  to  obstruction  of  the  ureter  or  ureters,  surgical 
intervention  is  necessary.  Occurring  in  the  course  of  neph- 
ritis, efforts  must  be  made  to  increase  elimination  through  the 
skin  and  bowels.  To  increase  elimination  through  the  skin, 
sweating  induced  by  heat  is  the  safest  method,  and  ma}?-  be 
accomplished  by  the  use  of  hot  wet  packs,  hot  dry  packs,  or 
electric  light  baths  (see  page  47  for  technic).  The  use  of 
pilocarpin  is  dangerous  in  many  cases,  and  when  emplo3^ed 
the  patient  must  be  closely  observed,  because  of  the  possibil- 
ity of  pulmonary  edema, 


ANOMALIES    OF    URINARY    SECRETION.  563 

Elimination  through  the  bowels  should  be  secured  by 
sodium  sulphate,  or  sodium  phosphate,  or  both.  y\n  effort 
should  be  made  to  secure  six  or  eight  watery  bowel  move- 
ments in  twenty-four  hours. 

If  there  is  no  edema  (and  there  is  likely  to  be  none  if  the 
anuria  is  due  to  metallic  poisons,,  such  as  phosphorus  or  mer- 
cury) 2  ounces  (60  mils)  of  water,  either  hot  or  cold,  should 
be  given  every  hour.  If  edema  occurs,  the  amount  of  water 
consumed  should  be  reduced  to  a  half  or  a  third  of  this 
amount. 

No  food  except  skimmed  milk  or  whey  should  be  given 
until  the  kidneys  begin  to  secrete.  Because  of  the  speed  with 
which  the  milk  is  carried  through  the  gastrointestinal  tract, 
due  to  the  administration  of  cathartics,  the  milk  should  be 
peptonized,  so  as  to  reduce  the  necessary  time  for  digestion 
as  much  as  possible. 

Diuretics,  such  as  squill,  diuretin,  Basham's  mixture,  and 
the  like  should  not  be  given.  If  there  is  evidence  of  cardiac 
distress  the  infusion  of  digitalis,  made  from  assayed  leaves, 
may  be  given  in  from  2-  to  4-  dram  (7.5  to  15  mils)  doses 
every  four  hours.  The  application  of  heat,  poultices  and  dry 
cup  to  the  loins  sometimes  seems  to  be  of  benefit.  When  the 
anuria  occurs  during  acute  infectious  diseases,  or  after  opera- 
tion, hot  rectal  enemata  of  coffee  are  of  value. 

Hematuria.  As  the  term  indicates,  blood  is  present  in  the 
urine.  It  is  a  symptom  and  not  a  disease  entity.  The  quan- 
tity of  blood  may  be  so  small  as  only  to  impart  a  faint  tinge 
to  the  urine,  or  it  may  be  so  large  as  very  greatly  to  change 
the  color.  Depending  upon  the  quantity  of  blood  and  the  age 
of  the  urine,  the  color  may  vary  from  a  light  smoky  tint  to 
a  light  red  or  a  dark  color  resembling  porter.  The  color  may 
change  from  brown  to  pink  on  standing  exposed  to  the  air. 
The  brown  tint  is  usually  due  to  the  presence  of  methemo- 
globin. 

The  hemorrhage  may  come  from  any  portion  of  the  genito- 
urinary tract.  Renal  hemorrhage  may  be  due  to  tuberculosis, 
carcinoma,  hypernephroma,  polycystic  degeneration,  acute 
nephritis,  especially  that  caused  by  turpentine,  hexamethy- 
lene-tetramin  (urotropin),  carbolic  acid  and  cantharides; 
infarcts,   calculus   pyelitis,   traumatism,   as  from   contusions, 


564  DISEASES    OF    THE    KIDNEYS. 

stab  wounds,  gunshot  wounds,  roug-h  palpation  of  a  movable 
kidney  and  parasites,  such  as  the  distoma  hematobium  and 
the  filaria  sanguinis  hominis. 

Ureteral  hemorrhage  may  result  from  carcinoma,  from 
traumatisms  such  as  may  occur  during  operations,  or  from 
the  passage  of  a  calculus. 

A'esical  hemorrhage  may  be  due  to  benign  or  malignant 
papilloma,  carcinoma  invading  the  bladder  from  surrounding 
structures,  calculi,  acute  cystitis,  and  varicose  veins  at  the 
vesical  neck. 

The  source  of  the  bleeding  may  be  urethral,  due  to  rough 
instrumentation,  passage  of  calculi,  and  traumatism  from 
external  violence.  Bleeding  may  occur  during  the  course  of 
a  severe  gonorrhea. 

Hematuria  is  sometimes  observed  in  purpura,  scurvy, 
malaria,  leukemia  and  hemophilia.  The  presence  of  large 
quantities  of  uric  acid  crystals,  and  more  especially,  crystals 
of  calcium  oxalate  may  cause  slight  hematuria.  Renal  hema- 
turia, onh-  discoverable  microscopically,  is  usually  found  in 
septic  nephritis  and  congestion.  In  some  cases  no  cause  can 
be  found  for  the  bleeding,  even  on  operation.  Such  a  condi- 
tion is  then  designated  as  essential  hematuria,  idiopathic 
hematuria,  renal  epistaxis  and  renal  hemophilia.  The  bleed- 
ing comes  from  one  or  both  kidneys,  without  discoverable 
adequate  exciting  cause,  and  may  be  associated  with  pain.  It 
occurs  usually  in  patients  under  30  years  of  age. 

The  recognition  of  hematuria  is  yerj  easy.  The  color  of 
the  urine,  however,  is  by  itself  not  diagnostic,  as  it  may  be 
produced  by  other  pigments.  Furthermore,  by  the  color  alone 
it  is  impossible  to  distinguish  hematuria  from  hemoglobinuria. 
The  finding  of  numerous  er}^throcytes  in  the  urine  by  micro- 
scopic examination  settles  the  diagnosis.  The  er3^throcytes 
may  retain  their  color  and  shape,  or  they  may  be  crenated  or 
appear  as  rings  without  color  (shadow  corpuscles).  Spores 
and  oil  globules  may  be  confusing,  but  a  very  little  experience 
enables  one  to  recognize  them  by  their  refractiveness  and 
great  variability  of  size. 

The  discovery  of  the  source  of  bleeding  may  be  very  diflfi- 
cult,  and  at  times  impossible.  In  cases  of  renal  hemorrhage 
the  urine  usually  contains  casts  of  various  kinds,  including 


ANOMALIES    OF   URINARY    SECRETION.  565 

blood-casts.  The  blood  and  urine  are  thoroughly  mixed,  and 
do  not  readily  separate  on  standing.  If  the  urine  is  voided 
in  two  portions,  both  will  be  equally  bloody.  If  the  blood 
comes  from  the  urinary  passages,  it  is  more  readily  separated 
by  sedimentation.  When  the  source  of  bleeding-  is  the  blad- 
der, the  first  portion  of  urine  voided  may  be  clear  and  the 
last  bloody.  The  blood  may  appear  at  the  end  of  micturition. 
In  washing  the  bladder  the  water  returns  blood-tinged,  while 
if  the  blood  comes  from  the  kidneys  or  ureters,  the  water  will 
return  clear.  When  the  urethra  is  the  source  of  bleeding  the 
first  portion  of  urine  voided  will  contain  the  blood ;  the  second 
portion  may  be  clear.  These  points  are  not  very  reliable, 
however,  and  a  cystoscopic  examination  should  be  made. 
This  procedure  is  always  necessary  in  renal  hemorrhage  to 
determine  whether  the  blood  comes  from  the  bladder  or  from 
one  or  both  kidneys.  Differential  ureteral  catheterization 
determines  from  which  kidney  the  blood  comes. 

As  hematuria  is  but  a  symptom,  it  is  necessary  to  seek  and 
treat  the  underlying  disease.  When  the  hemorrhage  is  severe, 
rest  in  bed  must  be  insisted'  upon,  and  continued  until  the 
evidence  of  blood  disappears  from  the  urine.  The  diet  should 
be  bland,  consisting  of  foods  rich  in  purin  bases,  and  such 
vegetables  as  rhubarb,  which  cause  oxaluria,  should  be 
avoided.  As  highly  concentrated  urine  is  very  irritating,  the 
specific  gravity  must  be  kept  low  by  the  drinking  freely  of 
water.  Pituitrin,  adrenalin,  calcium  lactate  may  be  given 
internally  as  hemostatics.  Hexamethylene-tetramine  (uro- 
tropin)  in  large  doses  is  recommended  by  some  authors,  but 
it  must  not  be  forgotten  that  this  drug,  even  in  moderate 
doses,  may  produce  hematuria.  In  essential  idiopathic  hema- 
turia, when  the  hemorrhage  is  severe  and  long-continued, 
good  results  have  been  reported  from  exposing  the  kidney  and 
incising  the  organ.  Why  the  hematuria  disappears  in  these 
cases  is  unknown.  The  appearance  of  blood  in  the  urine  may 
greatly  excite  the  patient,  in  which  event  it  may  be  necessary 
to  administer  bromides,  or  even  morphine. 

Hemoglobinuria.  By  this  is  meant  the  presence  of  hemo- 
globin or  methemoglobin  in  the  urine.  Up  to  a  certain  point, 
hemoglobin  released  from  the  erythrocytes,  destroyed  in  the 
body  is  converted  into  bile  pigment.     When,  however,  hemo- 


566  DISEASES   OF   THE   KIDNEYS. 

lysis  of  a  large  number  of  erythrocytes  suddenly  occurs  the 
hemoglobin  is  excreted  by  the  glomeruli  in  the  kidneys. 

Hemoglobinuria  occurs  after  poisoning  by  potassium  chlo- 
rate, carbolic  acid,  pyrogallic  acid,  naphthol,  phosphorus, 
arsenuretted  hydrogen,  carbonic  dioxid,  toulene-diamene,  and 
after  the  ingestion  of  poisonous  fungi  or  of  tainted  edible 
mushrooms.  Sometimes  it  also  occurs  in  scarlet  fever,  typhus 
and  typhoid  fevers,  yellow  fever,  syphilis,  scurvy,  purpura 
and  malaria.  In  the  latter  disease  it  is  commonly  seen  in  hot 
climates,  where  it  is  termed  malignant  malarial  hemoglo- 
binuria, and  in  Africa  is  called  black  water  fever.  It  may 
also  occur  after  extensive  burns,  during  absorption  of  exten- 
sive hemorrhagic  effusions,  after  violent  exercises,  and  after 
the  transfusion  of  blood  of  another  animal  of  different  species. 
The  hemoglobinuria  of  newborn  children  is  probably  the 
result  of  infection. 

There  is  a  peculiar  type — paroxysmal  hemoglobinuria — 
the  etiology  and  pathology  of  which  are  unknown.  It  occurs 
in  persons  apparently  otherwise  healthy,  and  in  the  majority 
of  instances  the  exciting  cause  appears  to  be  exposure  to  cold. 
That  some  other  factor  is  also  present  is  evidenced  by  the 
fact  that  the  disease  is  rare,  while  the  number  of  individuals 
exposed  to  very  low  temperature  is  great.  The  attack  comes 
on  suddenly,  and  may  be  preceded  by  chills  and  fever.  Vomit- 
ing and  diarrhea  may  be  very  prominent  symptoms,  and 
aching,  and  even  pain,  in  the  lumbar  regions  is  rather  com- 
mon. Cyanosis  of  the  ears  and  tips  of  the  fingers  may  appear 
during  the  attack.  A  paroxysm  may  occur  several  times  in 
one  day  and  then  cease ;  or  one  may  occur  on  several  succes- 
sive days. 

When  the  hemoglobinuria  is  slight  the  urine  may  be  pink 
and  transparent.  In  severer  cases  the  urine  has  a  deep  red 
or  brown  color,  approaching  to  blackness.  On  standing,  a 
very  dark,  sometimes  chocolate-colored  sediment,  is  deposited, 
which  is  found  to  be  composed  of  amorphous  brownish  gran- 
ules, sometimes  arranged  in  cast-like  formation.  A  charac- 
teristic that  distinguishes  hemoglobinuria  from  hematuria  is 
the  absence  of  erythrocytes ;  or,  if  present,  they  are  so  few 
as  to  be  negligible.  Urates  and  calcium  oxalate  crystals  may 
be  present  in  abundance.    The' urine  during  the  attack  always 


ANOMALIES   OF   URINARY   SECRETION.  567 

contains  albumin,  which  may  persist  for  a  time  after  tlie 
hemoglobin  or  niethemoglobin  disappears. 

While  the  underlying  cause  of  hemoglobinuria  may  be 
difficult,  or  even  impossible  to  determine,  the  recognition  of 
the  presence  of  the  hemoglobin  in  the  urine  is  easy.  It  must 
be  remembered,  though,  that  a  similar  appearance  of  thelirine 
may  be  i.nparted  by  urobilin  and  hematoporphyrin,  which  is 
a  pigment  very  similar  in  composition  to  hematin.  The  pres- 
ence of  hemoglobin  can  be  detected  by  Heller's  blood  test, 
which  is  carried  out  as  follows: 

To  a  test-tube  half  full  of  urine  5  drops  (0.31  mils)  of 
potassium  or  sodium  hydroxid  are  added  and  the  mixture 
heated.  If  hemoglobin  is  present,  a  brownish  red  or  blood  red 
flakey  precipitate  appears.  It  consists  of  the  phosphates  and 
carbonates  of  the  earthy  alkalies  which  have  carried  down 
with  them  the  hematin  that  has  been  formed  from  the  hemo- 
globin in  the  reaction.  In  alkaline  urines  the  above  method 
often  produces  no  precipitate,  because  the  phosphates  and  car- 
bonates have  already  completely  separated  out  spontaneously. 
The  necessary  quantity  of  phosphates  and  carbonates  may  be 
supplied  by  adding  to  the  specimen  about  the  same  volume  of 
a  normal  urine.  With  this  test  the  coloring  matters  which  ap- 
pear in  the  urine  after  the  use  of  chrysarobin,  senna,  rhubarb 
or  cascara  sagTada,  may  react  very  much  like  hemoglobin,  and 
so  may  lead  to  confusion.  But  in  the  latter  case  the  red  color 
addition  of  an  alkali  after  cooling,  and  the  decoloration  upon 
the  addition  of  acetic  acid,  are  characteristic. i  Another  very 
delicate  test  is  the  Turpentine-Guaiac  Test,  which  is  performed 
as  follows :  A  layer  consisting  of  a  mixture  of  equal  parts  of 
tincture  of  guaiac  (alcoholic  solution  of  resina  guaiac  1 :  5) 
and  oil  of  turpentine  is  carefully  stratified  upon  the  top  of  the 
urine.  If  hemoglobin  is  present  a  cloudy  ring  slowly  forms 
at  the  junction  of  the  two  layers,  gradually  becoming  an 
intense  blue.  The  oil  of  turpentine  must  be  ozonized,  i.e.,  old. 
The  urine  must  be  acid.  If  alkaline,  acidulate  with  acetic 
acid.- 

Examined  spectroscopically,  there  are  either  the  two  ab- 
sorption bands  of  oxyhemoglobin,  which  is  rare ;  or,  more 
commonly,  there  are  the  three  absorption  bands  of  methemo- 
globin,  of  which  the  one  in  the  red  near  C  is  characteristic. 


568  DISEASES    OF    THE    KIDXEYS. 

If  the  hemoglobinuria  has  been  caused  by  drugs,  their  use 
must  be  discontinued.  Its  incidence  during  the  course  of 
malaria  prompts  one  to  determine  whether  or  not  the  symp- 
tom is  due  to  the  great  destruction  of  the  erythrocytes  by  the 
Plasmodium,  or  is  referable  to  excessively  large  doses  of 
quinin.  AMien  attributable  to  syphilis,  active  antisyphilitic 
treatment  is  indicated.  It  is  probable  that  a  hemolytic  toxin 
is  the  cause  of  some  hemoglobinurias,  and  in  the  absence  of 
more  definite  etiolog}-  attempts  should  be  made  to  secure  free 
elimination  through  the  skin,  bowels  and  kidneys.  For  this 
purpose  hot  wet  packs  or  electric  light  baths  (see  page  584  et 
seq.)  should  be  employed,  three  or  four  watery  evacuations  of 
the  bowels  secured,  and  either  normal  salt  or  a  2  per  cent,  dex- 
trose solution  administrated  by  the  method  of  continuous 
enteroclysis  (see  page  583  et  seq.).  Arsenic  is  sometimes  of 
value,  and  the  inhalation  of  amyl  nitrite  is  recommended  by 
Chvostek,  who  claims  to  have  been  able  to  abort  attacks 
of  paroxysmal  hemoglobinuria  in  some  of  his  patients.  In 
the  paroxysmal  type  of  the  infection  the  patient  should  be 
kept  warm,  and  water  should  be  given  freely. 

Chyluria,  or  the  occurrence  of  chyle,  in  the  urine  is  a  rare 
condition,  and  may  be  parasitic  or  non-parasitic  in  orgin.  In 
the  tropics  the  parasitic  variety  is  more  common,  and  is 
caused  by  the  filaria  Bancroft!,  which  lodge  in  the  lymphatics. 
There  is  usually  a  dilatation  of  the  lymph-vessels  in  the  kid- 
neys and  in  the  abdominal  plexes.  The  non-parasitic  form  is 
extremely  rare,  and  the  real  causation  is  unknown.  The  urine 
is  of  an  opaque  white  color  resembling  milk.  If  blood  is 
admixed,  the  color  will  be  purplish  or  pale  red.  The  freshly 
voided  urine  is  faintly  acid  or  neutral.  Albumin  is  always 
found.  The  microscope  reveals  many  minute  fat  droplets.  In 
some  instances  coagula  form  in  the  urine,  either  after  voiding 
or  in  the  bladder.  In  the  latter  event,  micturition  may  be 
very  painful. 

The  course  and  duration  of  chyluria  are  extremely  vari- 
able. The  disease  may  last  for  months,  or  even  j^ears,  during 
which  time  long  intervals  occur  in  which  the  urine  appears 
normal.    Almost  all  cases  spontaneously  recover. 

No  effective  treatment  is  known  for  the  non-parasitic 
variety.     When  filaria  is  the  cause,  the  treatment  must  be 


ANOMALIES   OF   URINARY    SECRETION..  569 

directed  to  the  destruction  or  removal  of  the  parasites  from 
the  body,  and  prophylactic  measures  must  be  employed  to 
prevent  reinfection,  and  the  infection  of  healthy  persons. 

Albuminuria,  or  the  presence  of  albumin  in  the  urine  in 
quantity  sufficient  to  be  detected  by  the  ordinary  tests,  is 
always  abnormal.  The  significance  of  its  presence  depends 
upon  the  cause  and  the  source  from  which  it  came.  When 
it  is  associated  with  organic  changes  in  the  kidneys  it  is  of 
the  greatest  importance.  The  finding  of  albumin  in  the  urine 
makes  it  necessary  that  the  cause  be  thoroughly  investigated. 
Not  all  albuminurias,  however,  are  of  importance ;  and  it  must 
be  emphasized  that  the  discovery  of  albumin  does  not  make 
a  diagnosis  of  nephritis.  Not  infrequently  patients  are  seen 
who  have  been  made  neurasthenic,  or  even  hypochondriacal, 
by  the  erroneous  importance  given  to  the  accidental  discovery 
of  albumin  in  the  urine.  Albumin  may  be  added  to  the  urine 
as  a  result  of  disease  in  the  genito-urinary  tract  below  the 
level  of  the  kidneys,  such  as  inflammation,  especially  with  pus 
formation,  in  the  ureters,  bladder  or  urethra.  It  may  be 
present  as  the  result  of  contamination  of  the  urine  with  pus 
or  blood  from  the  vagina. 

Albuminuria  is  present  in  very  many  cases  of  fever,  and 
is  spoken  of  as  febrile  albuminuria.  It  has  no  serious  signifi- 
cance, and  disappears  when  the  temperature  returns  to  nor- 
mal. It  is  probably  the  result  of  a  cloudy  swelling  of  the 
renal  epithelium  due  to  the  toxin  that  caused  the  fever.  A 
few  hyaline  casts  are  often  in  association  with  this  form  of 
albuminuria. 

In  diseases  associated  with  profound  changes  in  the  blood, 
such  as  scurvy,  purpura,  leukemia,  pernicious  anemia,  albu- 
min may  be  found  in  small  quantities  in  the  urine.  It  is  not 
uncommonly  found  in  severe  anemia  secondary  to  carcinoma 
or  sarcoma.  Chronic  poisoning  with  lead,  mercury,  alcohol, 
etc.,  will  cause  albuminuria.  It  is  probable  that  the  albumin 
from  this  cause,  however,  is  the  expression  of  permanent 
organic  change  in  the  kidneys.  When  jaundice  occurs  albu- 
minuria is  very  often  associated,  due  either  to  the  irritant 
action  of  the  bile  on  the  kidney  cells  or  to  associated  toxins. 
Albuminuria  may  be  the  result  of  renal  congestion,  as  in 
cardiac  disease. 


570  DISEASES    OF   THE    KIDNEYS. 

Functional  albuminuria,  by  which  is  meant  the  appearance 
o£  albumin  in  the  urine  of  adolescent  individuals  whose  kid- 
neys are  normal  as  far  as  can  be  determined  and  whose  gen- 
eral health  is  good,  is  sometimes  seen.  It  is  usually  intermit- 
tent, and  is  apt  to  appear  after  the  patient  has  been  in  the 
upright  posture  for  some  time.  It  may  also  occur  after  exer- 
cise or  cold  bathing.  In  one  case  observed  the  albuminuria 
was  constant,  and  was  increased  by  cold  baths  and  exercise. 
No  evidence  of  renal  disease  could  be  found,  and  the  general 
health  of  the  young  man  was  good.  Ether  anesthesia  for  an 
appendectomy  brought  out  no  evidence  of  renal  insufficiency. 
The  absence  of  albuminuria  does  not  eliminate  a  possibility 
of  Bright's  disease. 

Bence-Jones  proteinuria,  by  some  referred  to  as  albumo- 
suria, is  an  albuminous  substance  which  is  foreign  to  the 
blood,  and  hence  readily  eliminated  by  the  kidneys.  It  is 
found  in  cases  of  multiple  myeloma.  Its  origin  is  unknown. 
It  is  not  an  indication  of  disease  of  the  kidneys.  The  quan- 
tity which  appears  in  the  urine  is  variable,  but  when  present 
is  usually  continuous.  Food  seems  to  have  no  influence  on 
the  quantity  of  the  protein  excreted.  Its  detection  in  the 
urine  is  easy  if  we  remember  that,  unlike  ordinary  albumin, 
it  coagulates  at  a  very  low  temperature.  It  is,  therefore, 
thrown  out  of  solution,  causing  turbidity  when  the  urine  is 
heated  to  122°  to  140°  F.  (50°  to  60°  C).  Raising  the  tem- 
perature to  a  higher  deg'ree  causes  a  disappearance  of  some 
of  the  turbidity.     It  may  be  tested  for  as  follows : 

Acidulate  the  urine  with  acetic  acid  and  add  a  small  quan- 
tity of  concentrated  sodium  chloride  solution.  Heat  the  urine 
to  122°  F.  (50°  C).  If  the  Bence-Jones  protein  is  present, 
the  urine  becomes  milky.  Heat  still  further;  at  140°  F.  (60° 
C.)  a  tenacious  precipitate  is  thrown  out,  tending  to  adhere 
to  the  sides  of  the  tube,  and  forming  a  granular  mass  which 
floats  on  top  of  the  urine.  As  the  boiling  point  of  the  urine 
is  reached,  the  precipitate  and  the  cloudiness  disappear,  reap- 
pearing when  the  urine  cools. 

Tests  for  Albumin.  In  a  rough  way  albumin  ma)^  be 
detected  as  follows :  Pour  urine  into  a  test-tube  until  it  is 
about  three-quarters  full.  Heat  the  upper  part  of  the  urine. 
If  turbidity  occurs  it  may  be  due  to  phosphates,  carbonates 


ANOMALIES    OF   URINARY    SECRETION.  571 

or  albumin.  If  the  cloudiness  disappears  upon  the  addition 
of  a  weak  acetic  acid  (1  to  9),  it  is  due  to  phosphates  or 
carbonates;  if  the  cloudiness  increases  on  the  addition  of 
acid,  it  is  due  to  albumin. 

Heller's  Test.  Put  about  ^  inch  (1.2  cm.)  of  urine  in  the 
test-tube.  With  a  pipette  allow  nitric  acid  to  run  slowly  down 
the  inside  of  the  tube.  The  acid,  being  much  heavier  than  the 
urine,  will  go  to  the  bottom.  If  albumin  is  present,  a  white 
ring  appears  at  the  margin  of  contact  of  the  two  liquids.  The 
density  and  depth  of  the  ring  depends  upon  the  amount  of 
albumin  present.  The  nitric  acid  may  be  placed  in  the  tube 
first,  and  the  urine  carefully  poured  on  top  by  allowing  it  to 
run  down  the  side  of  the  tube.  The  ring  of  turbidity  may  be 
due  to  the  presence  of  urates  or  uric  acid,  in  which  event  it 
will  disappear  if  the  contents  of  the  tube  is  warmed  (not 
boiled).  After  the  taking  of  certain  of  the  balsams  the  addi- 
tion of  nitric  acid  to  the  urine  may  cause  a  precipitate  of 
resinous  acids.  It  is  therefore  advisable  to  control  the 
Heller's  test  by  boiling  a  few  mils  of  urine  in  another  test- 
tube  and  adding  one-third  volume  of  nitric  acid ;  any  cloudi- 
ness must  then  be  due  to  albumin,  since  the  resinous  acids 
could  not  be  precipitated  because  of  the  heat  and  the  con- 
siderable excess  of  nitric  acid. 

When  a  large  amount  of  albumin  is  present,  the  ring  of 
contact  is  very  readily  seen.  When,  however,  but  a  very  faint 
trace  of  albumin  is  present,  unless  the  tube  is  viewed  against 
a  dark  background,  the  very  faint  ring  may  be  entirely  over- 
looked. In  the  writer's  laboratory  the  testing  for  albumin  is 
done  before  a  window,  the  glass  of  which  is  painted  black 
except  for  a  strip  about  ^  inch  (1.2  cm.)  wide  on  the  level  of 
the  eye  of  the  examiner.  Through  this  narrow  strip  of  white 
glass  enough  light  is  admitted  to  illuminate  the  test-tube  prop- 
erly, while  the  remaining  portion  of  the  black  glass  makes  a 
perfect  background,  against  which  even  the  faintest  whitish 
ring  of  albumin  is  easily  seen. 

Quantitative  Determination.  At  the  present  time  there  is 
no  accurate  method  that  is  applicable  by  the  average  clinician. 
The  one  most  in  vogue  is  the  Esbach  test.  The  apparatus 
consists  of  a  glass  test-tube  with'  a  rubber  stopper.  Near  the 
top  of  the  tube  is  a  mark  designated  R,  lower  down  one  desig- 


572  DISEASES    OF   THE    KIDNEYS. 

nated  U,  and  below  this  a  series  of  graduations  from  1  to  12, 
from  below  upward,  constituting  the  scale  from  which  is  read 
the  percentage  of  albumin  by  volume  per  1000  parts  of  urine. 
The  reagent  used  consists  of  picric  acid,  lO'Gms.  (154.3  grs.)  ; 
citric  acid,  20  Gms.  (308.6  grs.);  water,  1000  mils  (33.8  fg). 
In  making  the  test  fill  the  tube  (Esbach's  Albuminometer) 
with  urine  to  the  line  marked  "U'-  and  raise  the  level  of  con- 
tent to  the  mark  "R"  by  the  addition  of  the  reagent.  The 
tube  is  then  closed  with  the  rubber  stopper,  and  the  reagent 
and  urine  thoroughly  mixed  by  repeated  inversions  of  the  tube 
without  shaking.  Then  set  the  tube  aside  in  a  strictly  ver- 
tical position  for  twenty-four  hours,  -after  which  the  height  of 
the  precipitate  in  the  tube  is  read  ofif  on  the  scale,  the  results 
being  expressed  in  terms  of  parts  per  100  or  per  1000.  When 
expressed  in  percentage  we  must  remember  and  make  clear 
that  we  mean  per  cent,  by  volume  and  not  by  weight.  The 
percentage  by  weight  can  be  determined  accurately  by  pre- 
cipitating the  albumin,  drying  and  weighing  the  precipitate. 
Casts  and  Cylindroids.  Casts  are  found  in  the  tubules  of 
the  kidney.  Their  composition  is  unknown,  but  it  is  supposed 
that  the  material  of  which  they  are  composed  is  of  a  protein 
nature.  If  the  urine  of  healthy  individuals  is  allowed  to  stand 
for  some  hours  in  a  conical  sedimentation  glass  and  the  sedi- 
ment centrifugated,  a  very  few  hyaline  casts  may  sometimes 
be  found,  even  in  the  urine  of  young  adults.  Their  discovery 
in  the  urine  of  individuals  past  middle  life  has  no  serious 
significance  when  the  casts  are  very  few  in  number,  and  all 
other  evidence  of  renal  disease  absent.  Under  such  circum- 
stances their  appearance  is  probably  physiologic.  When  casts 
are  in  sufficient  number  to  be  found  with  ease,  they  are  evi- 
dence of  more  than  physiologic  change  in  the  kidneys,  but  do 
not  necessarily  mean  Bright's  disease.  They  may  be  found 
in  the  urine  in  renal  congestion  from  any  cause,  and  also  in 
renal  irritation,  as  in  oxaluria  and  in  marked  lithuria.  Bile 
appears  to  be  a  decided  renal  irritant,  and  in  almost  all  cases 
of  jaundice,  casts,  which  are  usually  bile-stained,  are  found. 
The  administration  of  mercury  in  medicinal  doses  is  some- 
times followed  by  the  appearance  of  hyaline  casts  in  consid- 
erable numbers,  and  is  due  to  the  fact  that  mercury  is  a 
direct  poison  to  renal  cells.     In  cases  of  chronic  interstitial 


ANOMALIES    OI'    URINARY    SECRETION.  5/3 

and  chronic  parenchymatous  nephritis  we  have  observed  the 
appearance  of  casts  in  excessive  numbers  after  the  giving-  of 
calomel.  As  stated,  the  appearance  of  an  occasional  hyaline 
cast  in  an  otherw^ise  normal  urine  excreted  by  an  apparently 
normal  person  has  no  significance.  This  is  important  to  bear 
in  mind  in  connection  with  life  insurance  examinations.  If, 
however,  a  few  casts  are  regularly  found  in  the  urine  of  an 
apparently  normal  individual,  even  though  albumin  is  absent, 
the  kidneys  must  be  suspected  of  disease,  and  every  means  in 
our  power  must  be  used  to  discover  the  factor  at  work ;  for 
when  we  stop  to  consider  how  insidious  is  the  onset  of  chronic 
interstitial  nephritis  and  that  by  the  time  symptoms  attract 
attention  to  the  disease,  the  prognosis  is  very  grave,  the 
importance  of  finding  the  cause  of  the  persistent  cylindruria 
becomes  obvious. 

Hyaline  casts  are  the  most  common  variety.  They  are 
transparent,  colorless,  and  often  difhcult  to  see,  especially  if 
the  microscopic  field  is  brightly  illuminated.  They  vary  in 
length  and  diameter.  The  ends  may  be  rounded,  flat  or 
irregular,  due  to  fracture.  They  are  found  in  all  types  of 
nephritis,  and  may  be  found  in  any  form  of  renal  disease, 
alone  or  in  association  with  others.  Usually  they  are  present 
in  urine  from^ patients  with  jaundice. 

Granular  casts  are  variable  in  length  and  diameter.  As  a 
rule  they  are  somewhat  wider  than  the  average  hyaline  cast, 
especially  when  observed  in  parenchymatous  nephritis.  The 
granules  may  be  highly  refractile,  and  may  be  composed  of 
droplets  of  albumin,  fat,  and  the  debris  of  disintegrated 
epithelium.  They  are  more  usually  found  in  chronic  Bright's 
disease. 

Epithelial  casts  are  composed  of  a  hyaline  matrix,  im- 
bedded in  which  are  epithelial  cells  derived  from  the  tubules 
of  the  kidneys.  They  are  usually  seen  in  acute  parenchyma- 
tous nephritis.  They  have  a  greater  diameter  than  the  hyaline 
or  granular  casts. 

Leucocytic  casts  are  composed  of  a  hyaline  matrix  in 
which  are  imbedded  leucocytes.  They  indicate  an  active 
inflammation  of  the  renal  substance,  and  are  often  found  in 
suppuration  of  the  kidneys. 


574  DISEASES   OF   THE   KIDNEYS. 

Fatty  casts  resemble  granular  casts.  They  are  differen- 
tiated by  the  high  refractive  power  of  all,  or  nearly  all,  the 
granules.  They  indicate  advanced  degeneration  of  the  renal 
parenchyma.  They  are  usuall}^  found,  with  epithelial  casts, 
in  chronic  parenchymatous  nephritis. 

Amyfoid  or  waxy  casts  resemble  the  hyaline  casts,  but  are 
larger  and  opaque  instead  of  transparent.  They  are  sup- 
posed, by  some  observers,  to  represent  the  end-product  of  the 
complete  degeneration  of  renal  cells.  They  are  usually  found 
in  chronic  parenchymatous  nephritis. 

C3dindroids  are  allied  to  the  casts,  but  are  less  significant, 
indicating  simply  irritation  of  the  renal  tubules.  Their 
appearance  is  extremely  varied.  Some  are  thin,  almost 
thread-like  bodies,  faintly  striated  and  of  variable  length, 
sometimes  stretching  entirely  across  the  field  of  the  micro- 
scope. Some  are  ribbon-like,  tortuous  and  bent.  Some 
resemble  hyaline  casts,  except  that  one  end  tapers  to  a  point. 
The  chief  characteristics  of  cylindroids  are  the  striations  and 
their  tapering  ends.  Enmeshed  in  their  structure  may  be 
uric  acid  or  calcium  oxalate  crystals  and  urates.  They  are 
seen  in  large  numbers  in  urine  containing  an  excess  of  cal- 
cium oxalate  crystals.  They  are  found  in  the  renal  tubules, 
and  their  appearance  in  the  urine  bears  no  relationship  to 
albuminuria. 

CIRCULATORY  DISTURBANCES  OF  THE 
KIDNEYS. 

Anemia.  Anemia  of  the  kidneys  may  be  a  part  of  the  gen- 
eral state  of  the  blood  or  may  be  purely  local,  due  to  narrow- 
ing of  the  lumen  of  the  blood-vessels  through  the  action  of  the 
nervous  system  or  to  compression  of  the  renal  artery  by  new 
growths,  adhesions  or  the  like.  The  anemia  produced  by 
vasoconstriction  is  of  comparatively  short  duration,  and  is 
observed  in  hysteria,  and  as  a  result  of  great  irritation  of  one 
kidney  or  ureter  by  a  calculus,  urethral  catheterization,  opera- 
tion on  one  kidney  or  traumatism. 

When  vasomotor  in  origin,  the  anemia  is  transitory  and 
leads  to  no  permanent  change  in  structure.  AVhen  caused  b}^ 
arterial  compression  it  may  be  sufficiently  prolonged  to  cause 
parenchymatous  degeneration. 


CIRCULATORY    DISTURBANCES.  575 

As  part  of  a  general  process,  renal  anemia  is  present  in 
pernicious  anemia,  and  in  those  diseases  characterized  by  a 
marked  secondary  anemia,  as  advanced  carcinoma,  tul^er- 
culosis,  and  the  like.  Under  these  conditions  the  anemia  is 
permanent,  and  leads  to  degeneration  of  the  renal  cells  with 
resulting-  diminution  of  function.  A  result  of  renal  anemia, 
regardless  of  cause,  is  diminution  in;  the  quantity  of  urine 
excreted,  or  even  complete  anuria. 

The  vasomotor  type  of  anemia  is  of  such  short  duration 
that  treatment  is  unnecessary.  When  anemia  is  due  to  com- 
pression of  the  renal  artery,  surgical  interference  is  requisite 
to  remedy  the  condition.  When  due  to  changes  in  the  blood, 
the  primary  disease  must  be  treated.  It  is  obvious  that  treat- 
ment directed  to  the  kidneys  must  fail  if  the  disease  produc- 
ing the  secondary  anemia  is  incurable. 

Hyperemia.  The  kidneys  may  be  the  seat  of  active  or 
passive  hyperemia.  As  in  other  organs  of  the  body,  a  cer- 
tain degree  of  hyperemia  is  physiologic.  Any  organ  that 
is  actively  functionating  contains  more  blood  than  during 
quiescence,  and  the  greater  the  functional  activity,  the  greater 
will  be  the  blood-supply.  The  kidneys,  being  among  the  prin- 
cipal organs  of  elimination,  are  called  upon  from  time  to  time 
to  remove  from  the  body  irritants  which  have  gained  entrance 
through  the  mouth,  or  which  have  been  formed  in  the  body, 
either  through  faulty  metabolism  or  bacterial  activity,  as  in 
the  infectious  fevers.  Active  hyperemia,  therefore,  is  present 
in  most  of  the  general  infections,  particularly  those  charac- 
terized by  fever,  in  various  disturbances  of  digestion  and 
metabolism,  notably  those  resulting  in  great  elimination  of 
calcium  oxalate  and  uric  acid  crystals,  and  as  the  result  of 
the  taking  of  such  irritant  drugs  as  turpentine,  copaiba,  can- 
tharides,  cubeb,  hexamethlenetetramin  (urotropin),  etc.  This 
state  may  also  be  brought  about  by  the  use  of  diuretics. 
Active  hyperemia  occurs  in  one  kidney  when  its  fellow  is 
removed  by  surgery  or  disease.  There  is  a  close  connection 
between  the  vessels  of  the  skin  and  those  of  the  kidney,  so 
that  chilling  of  the  skin  will  speedily  result  in  active  renal 
hyperemia. 

When  the  hyperemia  is  of  sufficient  grade,  the  kidneys 
are  swollen.     The  tension   on  the  capsule  may  cause   a  dull 


576  DISEASES   OF   THE   KIDNEYS. 

aching  sensation  in  the  lumbar  regions,  and  the  urine,  which 
at  first  was  increased  in  amount,  diminishes.  Albumin,  casts, 
er}'throcytes  and,  in  extreme  cases,  macroscopic  blood  may 
appear.  The  treatment  consists  in  the  recognition  of  the 
cause.  When  due  to  irritant  drugs  these  must  be  immediately 
discontinued.  Often  this  is  all  that  is  necessary.  When  the 
hyperemia  is  extreme,  marked  improvement  follows  the  use 
of  hot,  dry,  or  wet  packs  (see  page  584  et  seq.)  to  promote 
sweating,  the  application  of  dry  or  wet  cups  to  the  lumbar 
region  and  the  administration  of  a  saline  cathartic.  Mercury 
as  a  laxative  should  not  be  employed.  An  effort  should  be 
made  to  secure  five  or  six  watery  evacuations  from  the  bowels. 
As  the  blood-vessels  of  the  kidney  are  already  overfilled  with 
blood,  but  small  quantities  of  w^ater  should  be  given  until  it 
is  evident  that  elimination  through  the  kidneys  is  increasing, 
when  the  intake  of  water  should  be  increased. 

The  prognosis  is  good.  It  must  be  remembered,  however, 
that  if  the  congestion  is  long  continued,  organic  changes  may 
occur,  permanently  damaging  the  kidneys. 

Passive  Hyperemia.  This  condition  is  usually  encountered 
as  a  part  of  a  general  venous  congestion  secondary  to  cardiac 
insufficiency.  It  may  occur  late  in  the  course  of  pulmonary 
emphysema  and  fibroid  phthisis.  Ascites,  tumors  compress- 
ing the  renal  veins,  a  pregnant  uterus,  and  thrombosis  of  the 
inferior  vena  cava,  are  among  the  causes  of  passive  conges- 
tion. Evidence  of  passive  congestion  of  the  kidneys  occurring 
in  ascites  is  one  of  the  indications  for  the  performance  of 
paracentesis  abdominis. 

The  kidneys  enlarge  and  feel  tough  and  firm.  They  are 
deep  purple,  smooth,  and  the  capsule  strips  easily.  The 
stellate  veins  are  prominent.  On  section  the  striations  are 
unusuall}^  well  marked,  the  p^^ramids  are  deeply  reddened, 
and  the  blood-vessels  and  the  glomeruli  stand  out  promi- 
nently in  deep  red.  Alicroscopically,  the  capillaries,  especially 
the  glomeruli,  are  distended  with  blood,  and  there  may  be 
some  coagulated  fluid  in  Bow^man's  capsule  or  hyaline  casts 
in  the  tubules.  The  tubular  epithelium  may  show  some  cloudy 
swelling,  especially  wdien  the  passive  congestion  is  of  long 
standing,  in  which  event  the  interstitial  connective  tissue  may 
be  increased.     When  sufficiently  long  continued,  contraction 


CIRCULATORY    DISTURBANCES.  577 

of  the  connective  tissue  may  occur,  causing  a  diminution  in 
the  size  of  the  organs  and  leading  to  changes  similar  to  those 
of  a  diffuse  nephritis. 

Symptoms  arising  from  passive  hyperemia  of  the  kidneys 
are  too  insignificant  to  be  distinguished  among  those  that  are 
due  to  the  causative  factor,  such  as  cardiac  insufficiency,  pul- 
monary emphysema,  or  cirrhosis  of  the  liver.  It  is  detected 
by  the  observance  of  changes  in  the  urine,  which  consist  in 
the  excretion  of  a  greatly  diminished  quantity  of  dark  color 
and  high  specific  gravity,  which  may  be  over  1030. 

The  water  of  the  urine  is  diminished  very  much  more  than 
are  the  solid  constituents ;  consequently  upon  standing  for  a 
short  time  after  voiding,  the  urates  are  precipitated,  falling 
to  the  bottom  of  the  vessel  as  a  heavy  pinkish  sediment.  If 
the  urine  is  shaken  it  becomes  opaque.  Usually  a  small 
amount  of  albumin  is  present,  with  a  few  hyaline  casts  and 
erythrocytes.  Granular  casts  are  rarely  found  in  uncompli- 
cated cases.  Though  the  functional  activity  of  the  organs  is 
reduced,  uremia  does  not  supervene  in  the  absence  of  a  pre- 
existing nephritis.  Occurring  during  the  course  of  a  nephritis, 
the  diminution  of  function  may  be  sufficient  to  induce  uremia. 

When  the  patient  is  being  studied  for  the  first  time  it  may 
be  impossible  to  differentiate  passive  congestion  of  severe 
degree  from  nephritis,  especially  as  in  some  cases  of  cardiac 
decompensation  the  circulatory  disturbance  in  the  brain  and 
gastrointestinal  tract  may  originate  the  mental  changes  and 
vomiting  so  often  seen  in  uremia.  The  pronounced  cardiac 
changes  with  the  cyanosis  of  the  fingers,  toes,  lips,  ears,  etc., 
may  lead  one  to  the  correct  interpretation.  The  diagnosis  is 
confirmed  when,  under  appropriate  treatment  directed  to  the 
heart  successfully,  the  urinary  changes  disappear.  The  pres- 
ence of  red  blood-cells  in  the  sediment  is  an  important  diag- 
nostic sign  of  renal  congestion. 

There  is  no  treatment  indicated,  directed  especially  to  the 
passive  congestion  of  the  kidney,  as  the  condition  can  be 
relieved  only  when  the  disease  that  produces  the  general  pas- 
sive congestion  is  made  to  disappear.  When  the  renal  con- 
gestion is  due  to  pressure  on  the  renal  veins  by  ascites  or 
tumor  these  must  be  removed.  Occurring  late  in  pregnancy, 
it  need  cause  no  alarm  in  most  cases,  and  does  not,  in  itself, 
necessitate  abortion.  37 


578  DISEASES   OF   THE   KIDNEYS. 

NEPHRITIS. 

By  nephritis  is  meant  a  non-suppurative  inflammation  of 
both  kidneys,  first  clearly  described  by  Bright  about  1827,  and 
since  that  time  usually  spoken  of  as  Bright's  disease.  The 
term  Bright's  disease  today  takes  in  all  the  forms  of  nephritis, 
although  Bright  described  but  one  form,  namely,  an  inflam- 
mation of  the  kidneys  associated  with  marked  albuminuria 
and  edema  or  dropsy. 

Numerous  attempts  have  been  made  since  1827  to  con- 
struct a  classification  in  which  all  the  forms  of  Bright's  dis- 
ease could  be  placed,  but  thus  far  no  satisfactory  grouping  of 
the  various  lesions  has  been  made.  Based  upon  the  morbid 
anatomy  the  following  types  are  described  in  textbooks  of 
pathology : 

Acute  and  chronic  glomerulonephritis,  acute  and  chronic 
tubular  nephritis,  acute,  subacute,  chronic  interstitial  nephritis, 
and  arteriosclerotic  disease  of  the  kidneys.  Clinically,  these  dis- 
tinctions cannot  be  made,  and  at  times  it  is  difficult  and  even 
impossible  for  the  pathologist  to  say  from  his  examination  to 
which  type  the  kidney  belongs,  for  the  reason  that  changes 
in  all  the  parts  of  the  kidney  may  be  present  in  equal  degree. 
While  in  almost  every  nephritis  changes  are  found  in  the 
glomerules  and  tubules,  as  well  as  in  the  interstitial  tissue, 
the  disease  is  classified  according  to  the  location  of  the  pre- 
ponderating changes.  The  best  clinical  classification  is  that 
of  Senator,^  as  follows : 

1.  Acute  Nephritis. 

(a)  Parenchymatous  Nephritis  (tubular  and  glomerular). 

(b)  Diffuse  Nephritis. 

2.  Chronic   Diffuse   Nephritis  without   Induration    (chronic   paren- 

chymatous nephritis). 

3.  Chronic  Indurative  Nephritis  (contracted  kidney). 

(a)   Primary  Induration  (chronic  interstitial  nephritis). 
I  (&)  Secondary  Induration  (secondary  to  acute  inflammation). 

(c)  Arteriosclerotic  Induration. 

Acute  Parenchymatous  Nephritis.  By  this  is  meant  an 
acute  inflammation  or  degeneration  of  both  kidneys,  in  which 
the  glomerules,  tubules,  and  often  the  interstitial  tissue,  as 
well,  are  implicated.  The  lesions  are  most  usually  the  result 
of  an  infection,  and  may  develop  during  the  course  of  scarlet 


NEPHRITIS.  579 

fever,  diphtheria,  influenza,  typhus  fever,  typhoid  fever,  acute 
infectious  arthritis  (rheumatism),  and  septicemia  from  any 
focus.  The  renal  degeneration  or  inflammation  may  be  the 
result  of  bacterial  toxins  circulating-  in  the  blood,  or  of  the 
direct  action  of  bacteria  upon  the  renal  structure. 

Certain  drugs  and  chemicals  are  capable  of  causing  an 
acute  nephritis.  Among  them  are  mercury,  lead,  cantharides, 
turpentine,  carbolic  acid,  salicylic  acid,  potassium  bicarbonate, 
chloroform,  ether,  and  potassium  chlorate.  Acute  nephritis 
may  occur  in  ptomaine  poisoning;  and  it  is  probable  that 
highly  toxic  substances  generated  in  the  body  as  the  result 
of  perverted  metabolism  or  the  failure  of  certain  organs,  as 
the  liver,  to  destroy  poisonous  bodies  formed  during  the 
process  of  metabolism,  may  be  the  factor  of  some  cases  of 
Bright's  disease. 

As  a  rule  the  kidneys  are  larger,  heavier  and  more  vascular 
than  normal.  The  capsule  is  thin,  glistening,  tense,  strips 
easily,  and  in  some  instances,  when  incised,  the  kidney  sub- 
stance bulges  through,  giving  evidence  of  the  great  pressure 
beneath.  The  color  of  the  kidneys  is  dark  red  in  the  early 
stages ;  but  if  the  disease  has  been  of  sufificient  duration  to 
permit  fatty  degeneration  to  occur,  the  color  is  much  lighter, 
and  may  be  a  grayish  red.  If  the  lesions  are  chiefly  in  the 
glomerules,  these  appear  on  section  of  the  organ  as  dark  red 
points  against  the  grayish-red  background. 

Microscopically,  the  predominant  lesions  may  be  found  in 
the  glomerules  (glomerulonephritis),  in  the  tubules  (tubulo- 
nephritis),  or  may  be  scattered  throughout  the  kidneys,  in- 
volving also  the  interstitial  tissue  (diffuse  nephritis). 

Glomerulonephritis  is  the  type  found  in  scarlatina,  in 
streptococcus  infections,  and  in  poisoning  by  cantharidin. 
Bacteria,  lodged  in  clumps,  may  be  found  in  the  capillaries 
occluding  the  lumen.  The  toxin  of  the  organisms  or  the 
poison,  i.e.,  cantharidin,  may  injure  the  capillary  wall,  thus 
producing  an  occluding  thrombus,  and  the  loops  thus  occluded 
become  greatly  distended  by  a  mass  of  hyaline  material.  Tiie 
lumen  of  the  capsule  generally  contains  albuminous  material 
consisting  of  blood,  leucocytes  and  fibrin.  These  alterations 
interfere  greatly  with  the  permeability  of  the  glomerules,  and 
usually  are  associated  with  changes  of  an  inflammatory  char- 


580  DISEASES   OF   THE   KIDNEYS. 

acter  m  the  surrounding  connective  tissue  of  the  capsule. 
The  epitheHum  of  the  tubules  later  degenerates,  and  globules 
of  neutral  fat  and  cholesterin  esters  are  found  in  the  proto- 
plasm, provoking  a  swollen  appearance  of  the  cells.  Subse- 
quently, the  latter  shrink  in  size  and  finally  disappear,  caus- 
ing collapse  of  the  tubule. 

The  presence  of  wandering  cells  in  the  connective  tissue 
about  the  tubules  indicates  inflammatory  reaction.  The  very 
marked  disturbance  of  function  is  indicated  by  a  great  diminu- 
tion in  the  quantity  of  urine,  and  its  high  concentration  with 
the  presence  of  blood,  albumin  and  casts  of  various  kinds. 
Edema  of  the  subcutaneous  tissue  is  very  apt  to  be  present. 

When  the  lesions  affect  chiefly  the  tubules,  as  in  poisoning 
by  bichlorid  of  mercury,  potassium  bichromate,  and  similar 
agents,  there  is  a  very  marked  degeneration  and  necrosis  of 
the  cells  lining  the  tubules.  The  ultimate  result  of  destruc- 
tion of  epithelium  of  the  tubules  must  depend  upon  its  extent, 
since  if  it  be  partial,  the  tubule  may  be  perfectly  relined  from 
the  cells  which  remain,  while  if  it  be  complete,  the  collapse 
of  the  tubule  will  lead  shortly  to  destruction  of  the  glomer- 
ules  and  the  formation  of  a  scar  once  occupied  by  the  whole 
structure.'*  Edema  is  not  so  likely  to  appear  in  cases  of 
tubulonephritis.  In  diffuse  nephritis  the  interstitial  tissue  is 
affected,  as  well  as  the  glomerules  and  tubules,  and  this  part 
of  the  kidneys  is  edematous  and  infiltrated  with  round  cells. 
The  vessels  are  distended. 

Symptoms  may  appear  gradually  or  with  great  sudden- 
ness. When  the  disease  is  caused  by  bacteria,  as  in  strep- 
tococcus infection,  scarlet  fever,  influenza,  diphtheria  and 
typhoid  fever,  the  symptoms  are  very  likely  to  occur  late  in 
the  course  of  the  disease  or  even  during  convalescence.  Most 
usually  the  first  indication  of  nephritis,  is  diminution  in  the 
quantity  of  urine,  with  change  from  the  normal  amber  or  pale 
straw  color  to  a  deep  yellow  or  reddish  brown.  Coincident 
with  the  urinary  change  may  be  noted  fretfulness,  loss  of 
appetite  and  a  change  in  the  general  appearance  of  the  patient 
difficult  to  describe,  but  which  immediately  attracts  the  atten- 
tion of  the  observant  physician.  In  some  instances  the  first 
evidence  of  the  disease  is  the  sudden  appearance  of  edema  of 
the  subcutaneous  tissues  around  the  orbits  or  face,  arms  and 


NEPHRITIS.  581 

legs,  with  mental  dullness  and  headache.  Edema  in  heart  dis- 
ease usually  first  appears  in  the  ankles  toward  evening,  while 
in  acute  parenchymatous  nephritis  the  dropsy  first  appears 
under  the  eyes  in  the  morning. 

The  specific  gravity  of  the  urine  is  usually  1020  or  higher, 
the  color  dark  yellow,  or  even  bloody,  and  the  reaction 
usually  hyperacid.  Albumin  is  almost  invariably  present  in 
considerable  quantity,  and  in  a  few  instances  the  urine  be- 
comes almost  solid  upon  boiling.  Hyaline,  granular,  fatty 
and  epithelial  casts  are  present,  and  at  times  blood-casts 
appear.  Renal  epithelium  is  present  in  considerable  quantity, 
particularly  in  tubulonephritis.  Even  though  no  macroscopic 
evidence  of  blood  be  present,  erythrocytes  are  almost  always 
found  in  the  sediment,  some  well  preserved,  others  in  shadow 
form  or  crenated.  There  is  little  or  no  increase  in  the  num- 
ber of  leucocytes  in  the  urine.  The  quantity  of  urine  voided 
in  twenty-four  hours  may  be  as  small  as  10  or  12  ounces  (295.7 
to  355  mils).  In  severe  cases  total  suppression  may  occur  and 
persist  for  days. 

The  edema,  at  first,  is  likely  to  be  limited  to  the  orbital 
region  or  the  face  and  hands,  and  is  occasionally  unyielding, 
so  that  pitting  on  pressure  is  slight  and  sometimes  entirely 
absent.  The  facial  edema  smoothes  out  lines  of  expression, 
giving  the  patient  an  appearance  of  apathy,  which  is  some- 
times belied  by  the  alert  mentality.  Very  often,  however, 
there  is  actual  mental  dullness  and  drowsiness.  Later  the 
edema  may  increase,  involving  the  eyes,  back,  scrotum, 
abdominal  wall  and  anterior  thoracic  wall,  and  when  such  is 
the  case  the  cause  is  likely  to  be  cardiac,  as  well  as  renal. 
Effusions  in  the  serous  cavities  may  occur,  and  edema  of  the 
lungs  or  glottis  may  cause  death.  As  a  rule,  however,  the 
edema  is  not  so  extreme  nor  so  extensive  as  in  the  chronic 
parenchymatous  cases.  When  the  epithelium  of  the  tubules 
has  suiifered  damage  almost  to  the  exclusion  of  the  glom- 
erules,  as  is  the  case  in  acute  bichlorid  of  mercury  poison- 
ing, edema  is  very  slight  and  often  entirely  absent.  In  a  case 
recently  reported  by  the  authors'"*  there  was  complete  anuria 
for  four  days  without  edema  and  without  evidence  of  uremia. 

Headache  is  often  a  very  troublesome  SA^mptom,  and  is 
due  probably  to  toxemia  or  edema  of  the  cerebral  meninges. 


582  DISEASES    OF    THE    KIDXEYS. 

Xausea  and  vomiting,  usually  toxic  in  origin,  are  common, 
and  in  some  instances  even  water  is  not  retained  in  the 
stomach.  Constipation  is  more  commonh*  observed  than 
diarrhea.  Retinitis,  with  or  without  hemorrhages,  is  present 
in  some  cases. 

Pericarditis  is  a  rather  frequent  complication  in  cases  of 
microbic  origin,  and  may  cause  a  fatal  termination.  Lobular 
pneumonia  is  sometimes  found.  Lobar  pneumonia  as  a  com- 
plication is  rare. 

The  occurrence  of  a  purpuric  eruption  indicates  a  severe 
infection,  probably  streptococcal,  and  has  a  ver}-  grave  prog- 
nostic significance. 

Uremia  may  occur  during  the  course  of  the  disease,  and 
ma}-  cause  death  in  convulsions  and  coma.  Uremic  manifes- 
tations are  usually  seen  in  terminal  stages  of  chronic  forms 
of  the  disease. 

Probably  a  considerable  number  of  cases  of  acute  nephritis 
make  a  complete  recover}-.  One  is,  however,  not  justified  in 
recording  a  case  as  cured  until  the  patient  has  been  symptom- 
free  for  months,  and  repeated  urinalyses  have  demonstrated 
the  persistent  absence  of  the  disease,  because  there  is  a  strong 
tendencv  to  a  transition  from  an  acute  to  a  chronic  process, 
during  which  transition  there  is  likely  to  be  a  very  great 
amelioration  of  all  the  symptoms  and  signs  of  the  disease. 

Since  acute  nephritis  is  so  likely  to  occur  in  those  suf- 
fering from  acute  infectious  diseases,  notably  scarlet  fcA-er, 
influenza,  diphtheria  and  typhoid  feA'er,  it  is  advisable  to 
regard  these  patients  as  potential  nephritics,  and  throughout 
the  course  of  the  infection  to  attempt  in  ever}-  manner  to 
protect  the  kidneys.  As  the  bacteria  and  toxins  generated  in 
the  infectious  diseases  are  eliminated  to  a  large  extent 
through  the  kidneys,  one  should  aim  to  dilute  the  urine  so 
as  to  render  them  as  little  irritating  as  possible.  This  may 
be  accomplished  by  the  administration  of  water  by  mouth,  2 
to  3  pints  (1  to  1.5  1.'/  per  diem  beirrg  given,  in  addition  to  the 
liquids  ingested  as  foods,  i.e.,  milk.  A  record  of  the  quantity  of 
liquid  ingested  and  the  quantity  of  urine  excreted  daily  should 
be  kept.  The  amount  excreted  by  an  average  adult  should 
be  50  to  60  ounces  (1500  to  1800  mils),  and  is  usually  from  2 
to  8  ounces  (60  to  240  mils)  less  than  the  quantity  ingested.    If 


NEPHRITIS.  583 

diarrhea,  vomiting  or  profuse  sweating  occurs,  the  difference 
will  be  greater.  If,  in  the  absence  of  any  adequate  cause,  the 
difference  is  very  great,  it  indicates  an  overtaxing  of  the  kid- 
neys and  circulatory  apparatus,  which  is,  of  course,  harmful. 
It  is  signally  important  to  arrest  polyuria,  as  it  causes  exces- 
sive renal  work.  If  for  any  reason  such  as  vomiting  and  cer- 
tain types  of  delirium  in  which  the  patient  cannot  be  aroused 
sufficiently  to  swallow,  the  water  must  be  given  per  rectum, 
by  the  additioa  of  sufficient  glucose  to  make  a  2  per  cent, 
solution,  the  absorbability  of  the  water  will  be  increased  and 
the  tendency  to  rectal  irritability  lessened.  The  solution 
should  be  given  either  by  the  drop  method  or  by  continuous 
enteroclysis. 

The  apparatus  necessary  for  the  use  of  the  drop  method 
consists  of  a  soft  rubber  rectal  tube  or  catheter,  a  reservoir 
with  a  capacity  of  at  least  one  quart,  rubber  tubing  to  con- 
nect the  rectal  tube  with  the  reservoir,  and  a  pinch  cock.  One 
pint  (473.1  mils)  of  the  dextrose  solution  at  a  temperature  of 
105°  to  110°  F.  (40.5°  to  43.3°  C.)  is  placed  in  the  reservoir 
and  the  diameter  of  the  connecting  tube  constricted  until  the 
desired  number  of  drops  per  minute  escape  from  the  rectal 
tube.  The  rate  of  flow  in  most  cases  should  be  30  drops  (1.9 
mils)  per  minute.  A  stoppered  bottle  containing  water  at 
105°  to  110°  F.  (40.5°  to  43.3°  C.)  is  placed  in  the  reservoir 
to  maintain  the  temperature  of  the  surrounding  liquid,  and 
changed  as  often  as  necessary  to  keep  the  temperature  at  the 
desired  degree.  The  rectal  tube  is  inserted  about  4  inches 
(10.1  cm.)  into  the  rectum,  and  may  be  retained  in  place  by 
a  bandage  or  strips  of  zinc  oxid  plaster. 

The  same  apparatus  may  be  used  for  continuous  entero- 
clysis, the  technic  of  which  differs  from  the  drop  method  in 
that  the  reservoir  is  placed  but  2  or  3  inches  (5.0  to  7.6  cm.) 
above  the  level  of  the  patient's  buttocks,  and  the  connecting 
tube  is  not  constricted.  Hydrostatic  pressure  regulates  the 
quantity  of  water  in  the  rectum,  increasing  pressure  in  which 
will  force  some  of  the  fluid  back  into  the  reservoir,  while 
decreasing  pressure  allows  more  of  the  solution  to  enter  the 
rectum.  It  is  not  necessary,  in  this  method,  to  resort  to  meas- 
ures to  keep  the  water  in  the  reservoir  warm. 

In  view  of  the  fact  that  the  kidneys  are  irritated  by  the 


584  DISEASES    OF   THE    KIDNEYS. 

toxins  of  disease,  the  administration  of  certain  drugs,  which 
in  toxic  doses  produces  a  nephritis,  should  be  avoided.  Of 
such  drugs,  mercury,  turpentine,  salycylic  acid,  copaiba, 
potassium  chlorate,  and  carbolic  acid  are  striking  examples. 
The  skin  should  be  kept  in  good  condition  by  warm  baths. 
Rubs  with  alcohol  of  greater  strength  than  50  per  cent,  should 
not  be  employed,  because  of  the  likelihood  of  removing  the 
natural  oil  and  impairing  the  efficiency  of  the  skin.  Hydro- 
therapy may  be  necessary  to  combat  high  fever,  and  for  that 
purpose  cold  sponge  baths  are  better  than  cold  plunge  baths 
or  cold  packs. 

A  daily  examination  of  the  urine  is  important,  in  order  to 
detect  abnormalities  such  as  hyperacidity  and  concentration, 
the  early  recognition  and  counteraction  of  which  protects  the 
kidney. 

If  the  disease  be  the  result  of  the  taking  of  drugs  or  the 
inhalation  of  turpentine  (as  may  result  from  sleeping  in  a 
freshly  painted  room),  these  causative  factors  should  be 
removed.  The  patient  should  be  confined  to  bed  and  kept 
warm,  and,  if  necessar}^,  should  sleep  between  blankets  and 
wear  flannel  night  clothes.  The  temperature  of  the  room 
should  be  maintained  at  70°  F.  (21.1°  C),  but  care  must  be 
taken  to  see  to  it  that  the  air  is  fresh.  Excitement  and  noise 
in  the  sick  room  should  be  avoided,  as  it  is  important  to  rest 
the  mind  as  well  as  the  body.  For  this  reason,  also,  the 
patient  should  not  be  allowed  to  transact  business.  Usually 
the  maintenance  of  mental  rest  is  the  most  difficult  task,  and 
frequently  the  co-operative  efforts  of  relatives  and  friends 
must  be  enlisted. 

The  diet  is  of  great  importance,  and  frequently  becomes 
a  very  difficult  problem.  A  cardinal  principle  in  the  treat- 
ment of  acute  nephritis  is  to  lighten  the  work  of  the  kidneys 
as  much  as  possible.  The  chief  indication  is  to  avoid  foods 
which  may  irritate  the  kidneys  or  increase  the  work  of  those 
organs.  In  severer  cases  no  food  of  any  kind  need  be  given 
for  several  days,  especially  if  nausea  and  vomiting  are  trou- 
blesome. Later  skimmed  milk  is  given,  either  alone  or  com- 
bined with  lime-water.  The  addition  of  the  latter  is  often 
useful  when  nausea  follows  the  taking  of  milk.  Six  ounces 
(180   mils)    of    skimmed    milk    are    given    every    three    hours 


NEPHRITIS.  585 

between  7  a.m.  and  10  p.m.,  and  once  during  the  night,  if  the 
patient  is  awake.  As  this  supplies  but  300  or  400  calories  a 
day,  the  skimmed  milk  diet  must  not  be  continued  more  than 
a  few  days  or  a  week,  at  the  end  of  which  time  whole  milk 
is  substituted  for  a  few  days,  thus  raising  the  number  of 
calories  to  approximately  600  per  day.  As  improvement  in 
the  kidne3's  goes  on,  the  caloric  value  of  daily  food  consump- 
tion is  increased  by  the  addition  of  cream,  sugar  and  other 
carbohydrates,  such  as  crackers,  zwieback,  toast  and  rice. 
Meats  should  be  avoided,  because  the  acutely  inflamed  kid- 
neys eliminate  with  difficulty  the  products  of  nitrogen  metab- 
olism. Creatinin  is  eliminated  with  difficulty  by  the  diseased 
kidneys,  and  as  this  substance  is  plentiful  in  meat  extracts 
and  broths,  these  should  be  prohibited.  Sodium  chlorid 
should  be  strictly  interdicted,  if  there  is  edema ;  otherwise,  it 
may  be  used  sparingly.  Oranges,  lemons  and  grapefruit  may 
be  allowed.  It  is  most  important  to  avoid  intestinal  toxemia, 
because  the  added  burden  thrown  upon  the  functionally 
impaired  kidneys  may  be  sufficient  to  induce  uremia. 

In  cases  in  which  the  kidneys  are  unable  to  eliminate 
water,  as  in  glomerulonephritis,  edema  will  be  observed.  In 
these  cases  the  intake  of  fluid  must  be  limited,  otherwise  the 
dropsy  will  be  increased,  and  a  burden  thrown  upon  the  cir- 
culation that  may  provoke  dilatation  of  the  heart,  thus  add- 
ing very  materially  to  the  gravity  of  the  case.  When  there 
is  no  edema  the  amount  of  liquid  need  not  be  restricted,  and 
in  these  cases  the  patient  should  be  encouraged  to  drink 
freely  of  water.  There  are  many  waters  recommended  in 
Bright's  disease,  but  it  is  very  doubtful  if  their  value  is  any 
greater  than  that  of  plain,  pure  water. 

In  the  early  stages  of  the  disease  .elimination  through  the 
bowels  and  skin  is  of  the  utmost  importance.  The  bowels 
should  be  made  to  move  four  or  five  times  daily  for  the  first 
two  or  three  days,  and  for  this  purpose  sodium  sulphate  or 
sodium  phosphate,  or  both,  should  be  used.  If,  because  of 
nausea,  the  salines  cannot  be  used,  elaterin  or  compound  jalap 
powder  should  be  employed. 

The  skin  is  a  very  important  organ  of  elimination,  and 
should  be  kept  warm  and  in  good  condition  by  a  daily  warm 
bath  with  castile  soap  and  water.     Free  sweating  should  be 


586  DISEASES   OF  THE  KIDNEYS. 

induced  once  daily,  preferably  by  hot  packs  or  electric  light 
baths.     If  the  patient  is  not  very  ill  he  may  take  a  hot  tub  . 
bath  at  a  temperature  of  from  105°  to  108°  F.  (40.5°  to  42.2° 
C.)  for  from  five  to  eight  minutes,  and  then  immediately  re- 
turn to  bed  between  hot  blankets,  with  hot-water  bottles. 

A  hot  wet  pack  is  a  very  efficient  method  of  inducing  free 
sweating,  and  is  given  as  follows :  The  top  bed  covers  are 
replaced  with  a  blanket,  a  rubber  sheet  or  oilcloth,  or  several 
thicknesses  of  paper  are  placed  over  the  mattress  to  keep  it 
dry,  and  over  this  is  spread  a  blanket.  The  patient  is  first 
wrapped  in  a  dry  sheet,  and  then  covered  with  the  top 
blanket,  until  the  two  wet  blankets  are  ready.  These  are 
prepared  by  soaking  them  in  water,  the  temperature  of  which 
is  about  150°  F.  (65.5°  C),  leaving  one  corner  of  the  upper 
and  lower  edge  of  each  blanket  out  of  the  water.  To  facili- 
tate wringing,  these  corners  should  be  diagonally  opposite 
each  other.  Having  wrung  the  blankets  very  dry,  one  is 
passed  under  the  patient,  and  the  other  one  placed  over 
him,  the  ends  being  carried  under  and  around  the  arms  and 
adjusted  so  as  to  bring  the  corners  over  the  shoulders;  the 
legs  are  then  enclosed,  and  the  ends  of  the  hot  wet  blanket 
upon  which  the  patient  is  lying  wrapped  about  him.  He  is 
then  covered  with  a  dry  blanket,  the  ends  of  which  are  tucked 
under  the  shoulders,  sides  and  feet.  The  left  edge  of  the 
under  dry  blanket  is  then  brought  over  and  tucked  under  the 
right  side,  then  the  right  edge  of  the  blanket  is  brought  over 
and  tucked  under  the  left  side.  A  towel  is  placed  between 
the  blankets  and  the  patient's  neck  and  chin.  Hot-water  bot- 
tles are  placed  along  the  sides  and  at  the  feet  of  the  patient, 
and  then  the  oilcloth  or  rubber  sheet  is  brought  over  the 
patient,  and  over  this  is  spread  the  bed  clothes.  Finally,  an 
ice  cap  is  placed  upon  the  head. 

Sweating  begins  promptly  in  most  cases,  and  may  be  con- 
tinued from  ten  to  thirty  minutes,  depending  upon  the  state 
of  the  circulation.  The  pulse  is  studied  at  the  temporal 
artery,  and  if  irregularity  occurs,  the  bath  must  be  discon- 
tinued. While  in  the  bath  a  glass  of  hot  lemonade,  hot  water, 
or  ^^ichy  should  be  given. 

Care  must  be  taken  not  to  burn  the  patient.  The  common 
cause  of  burns  are :   Wringing  out  the  blankets  in  water  that 


NEPHRITIS.  587 

is  too  hot,  or  not  wringing  them  dry  enough ;  placing  the  hot- 
water  bags  next  the  wet  blankets  and  thus  causing  steam.  It 
is  also  very  important  to  prevent  the  entrance  of  air  under 
the  blankets  while  the  patient  is  lying  in  the  pack,  as  this 
would  cause  chilling  of  the  skin  and  induce  an  increase  of  the 
renal  congestion.  For  the  same  reason  chilling  must  be 
avoided  when  the  patient  is  removed  from  the  pack,  by  tak- 
ing the  precaution  to  remove  the  wet  blankets  under  cover 
of  the  dry  blanket. 

In  homes  lighted  by  electricity  an  electric  light  bath  may 
be  employed  to  induce  sweating.  The  bed  is  protected  by  a 
rubber  sheet,  oilcloth  or  several  layers  of  paper,  and  over  it 
is  spread  a  blanket,  the  right  edge  of  which  is  spread  over  the 
patient,  and  tucked  under  his  left  side.  The  left  edge  is 
tucked  under  the  right  side,  and  a  towel  is  placed  between 
the  blanket  and  the  patient's  neck  and  chin.  A  frame  of  iron 
rods  or  of  barrel  hoops  is  arranged  over  the  bed  from  the 
patient's  neck  to  the  feet,  and  from  these  hoops  is  suspended 
a  board  containing  six  to  eight  incandescent  electric  light 
bulbs.  Care  must  be  taken  to  avoid  defective  insulation  of 
the  wires.  The  frame  is  then  covered  with  a  blanket,  over 
which  is  spread  a  rubber  sheet,  oilcloth,  or  several  layers  of 
paper,  and  over  these  another  blanket.  Currents  of  air  from 
the  outside  must  not  be  allowed  to  enter  the  improvised 
cabinet. 

A  hot-air  bath  may  be  used  to  induce  sweating.  A  frame 
such  as  described  for  the  electric  bath  is  placed  over  the 
patient,  and  hot  air  from  an  alcohol  or  kerosene  lamp  resting 
upon  the  floor  is  conducted  within  the  cabinet  through  a 
metal  pipe.  If  the  patient  is  able  to  leave  the  bed  a  cabinet 
bath  may  be  employed.  The  cabinet  consists  of  a  square 
enclosure  made  of  moisture-proof  material,  so  arranged  that 
the  top  fits  snugly  about  the  neck  of  the  subject,  who  enters 
the  cabinet  nude,  and  sits  on  a  chair  with  a  solid  wooden  seat. 
An  alcohol  lamp  under  the  chair  supplies  the  heat.  Cold  com- 
presses or  an  ice-bag  should,  be  placed  on  the  head.  Sweat- 
ing, which,  as  a  rule,  begins  quite  promptly  and  is  profuse, 
should  not  be  allowed  to  continue  too  long.  The  bath  should 
be  discontinued  at  the  end  of  fifteen  or  twenty  minutes,  and 
immediately    upon    leaving    the    cabinet    the    patient's    body 


588  DISEASES    OF   THE    KIDNEYS. 

should  be  quickly  sponged  with  warm  water  and  dried,  the 
patient  getting  into  bed  immediately  thereafter.  Chilling  can 
occur  very  quickly  after  leaving  the  cabinet,  in  which  the  tem- 
perature is  160°  F.  (71.1°  C.)  or  higher.  The  room  in  which 
the  bath  is  taken  must,  therefore,  be  warm,  and  the  cabinet 
placed  not  only  in  the  same  room  as  the  bed,  but  also  as  near 
the  bed  as  is  conveniently  possible. 

The  induction  of  diaphoresis  by  the  use  of  pilocarpin  may 
be  fraught  with  so  much  danger  that  only  in  those  rare 
instances  where  sweating  cannot  be  induced  by  one  of  the 
physical  measures  just  indicated,  is  its  use  justified.  It  is  a 
distinct  cardiac  depressant,  and  in  acute  nephritis  a  great 
strain  is  suddenly  thrown  upon  the  myocardium  by  the  action 
of  this  drug.  It  is,  therefore,  bad  practice  to  administer  a 
drug  which  reduces  the  ability  of  the  heart  to  do  its  work. 
Furthermore,  pilocarpin  not  only  stimulates  the  sweat  glands 
to  action,  but  also  may  induce  such  a  profuse  bronchial  secre- 
tion as  seriously  to  embarrass  respiration,  or  even  cause 
death.  Finally,  the  diaphoresis  produced  by  pilocarpin  can- 
not be  checked  at  will,  as  is  the  case  with  that  produced  by 
external  means. 

There  are  no  drugs  that  have  a  specific  influence  in  acute 
nephritis.  Cantharides,  copaiba,  cubebs,  turpentine,  and  gin 
do  positive  harm.  The  best  diuretics  are  milk  and  water. 
Lemonade  may  take  the  place  of  some  of  the  water.  The 
addition  of  a  teaspoonful  (4  mils)  of  cream  of  tartar  to  the  pint 
of  lemonade  increases  the  diuretic  action,  and  has  a  somewhat 
laxative  effect.  The  cream  of  tartar  should  first  be  dissolved 
in  hot  water,  as  it  is  not  very  soluble  in  cold  water.  Sodium 
bicarbonate  by  mouth  or  per  rectum  is  often  beneficial  when 
toxemia  is  marked.  When  the  heart  is  weak,  especially  if 
there  is  a  falling  blood-pressure,  digitalis  is  indicated.  The 
infusion,  freshly  made  from  assayed  leaves,  is  the  best  prep- 
aration to  use.  The  dose  should  be  2  to  4  drams  (7.5  to  15 
mils)  every  three  or  four  hours.  Sodium  theobromin  salic- 
ylate (diuretin)  in  doses  of  10  grains  (0.65  Gm.)  and  caffein, 
are  also  valuable  when  the  heart  shows  signs  of  failing. 

"^Vhen  edema  of  the  lungs  occurs,  venesection  is  often  of 
great  service.  It  is  very  easily  accomplished  as  follows :  The 
skin  over  the  median  basilic  vein,  preferably  of  the  left  arm, 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  589 

is  washed  with  soap  and  water,  followed  by  alcohol,  and  then 
painted  with  10  per  cent,  tincture  of  iodin.  The  arm  is 
tig'htly  constricted  above,  but  complete  constriction  of  the 
brachial  artery  should  be  avoided,  because  if  some  arterial 
blood  is  pumped  into  the  arm  the  pressure  in  the  constricted 
vein  is  higher,  and  bleeding  occurs  more  readily.  When  the 
vein  is  well  dilated  a  sharp-pointed  curved  bistoury  is  plunged 
throug-h  the  skin  into  the  lumen  of  the  vein,  which  is  incised 
by  carrying  the  bistoury  outward  to  the  surface. 

The  quantity  of  blood  withdrawn  varies  with  the  individ- 
ual patient.  As  a  rule,  in  adults  from  8  to  30  ounces  (240  to 
900  mils)  are  withdrawn.  The  bleeding  is  stopped  if  faint- 
ness  or  nausea,  not  due  to  psychic  shock,  occurs. 

Dry  cupping  over  the  lumbar  regions  is  sometimes  used. 
Its  value  lies  in  the  relief  of  pain  in  these  regions.  It  has  no 
influence  on  the  course  of  the  disease  in  the  kidneys.  The 
technic  is  as  follows:  A  swab  wet  with  alcohol  is  ignited 
and  held  in  a  small  thick  glass  for  a  few  seconds.  Then 
quickly  place  the  glass  over  the  region  to  be  cupped.  Apply 
in  this  manner  as  many  glasses  as  necessary  to  cover  the  area 
to  be  cupped.  Heating' the  air  in  the  glass  causes  the  air  to 
expand.  As  cooling  takes  place  a  partial  vacuum  is  formed, 
to  fill  which  the  skin  is  drawn  into  the  glass.  The  glasses 
should  be  removed  when  the  skin  within  becomes  a  deep  red. 
If  they  are  allowed  to  remain  too  long,  ecchymosis  will  result. 
In  removing,  insert  a  finger  under  the  rim,  otherwise  pain 
will  be  caused  whenever  much  tissue  has.  been  drawn  into  the 
glass. 

The  application  of  heat,  e.g.,  a  hot-water  bottle,  to  the 
lumbar  region  will  answer  the  purpose  as  well  as  does  the 
cupping. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

This,  a  chronic  inflammation  of  the  kidneys,  of  which  the 
epithelial  degeneration  is  the  most  prominent  feature,  is  not 
always  easily  differentiated  from  chronic  interstitial  nephritis. 
In  many  instances  it  seems  to  develop  from  the  acute  form. 
Just  how  often  this  happens  it  is  impossible  to  say,  as  acute 
nephritides,  which  become  symptom-free,  pass  out  of  obser 


590  DISEASES    OF    THE    KIDNEYS. 

vation;  and  in  the  study  of  the  chronic  cases  dependable  his- 
tories are  often  impossible  to  obtain. 

The  disease  develops  so  insidiously  and  advances  so  im- 
perceptibly that  its  inception  escapes  notice,  and  for  this  rea- 
son a  cause  is  often  difficult  to  find.  In  general,  it  may  be 
stated  that  the  same  factors  which  induce  acute  nephritis  are 
capable  of  causing  the  chronic  type.  The  difference  in  effect 
depends  upon  the  amount  of  injury,  and  the  length  of  time 
in  which  the  injurious  agent  is  effective.  Thus,  infection 
with  virulent  streptococci  would,  in  all  probability,  result  in 
an  acute  inflammation;  while  infection  with  less  virulent 
organisms  might  give  rise  to  a  low  grade  inflammation,  tend- 
ing toward  chronicity.  Recurring  mild  infection  is  a  common 
cause  of  latent  chronic  parenchymatous  nephritis. 

The  types  of  streptococci  provocative  of  chronic  endar- 
teritis and  arthritis  are  capable  also  of  producing  a  chronic 
diffuse  renal  inflammation.  The  most  common  foci  from 
which  these  organisms  are  distributed  are  the  teeth,  tonsils, 
accessory  sinuses,  mastoid,  middle  ear,  prostate,  seminal  vesi- 
cles, gall-bladder,  and  appendix ;  sometimes  they  are  derived 
from  a  salpingitis. 

Among  the  specific  causes  that  are  usually  given  for 
chronic  parenchymatous  nephritis,  when  it  is  not  secondary 
to  acute  nephritis,  are  various  chronic  constitutional  diseases, 
especially  those  which  lead  to  anemia  and  cachexia.  In  this 
connection  chronic  tuberculosis  must  be  mentioned.  It  Has 
been  estimated  by  some  that  25  per  cent,  of  the  cases  of 
chronic  parenchymatous  nephritis  are  in  association  with 
tuberculosis.  The  disease  is  very  commonly  found  in  chil- 
dren affected  with  hereditary  syphilis.  Estivo-autumnal  ma- 
laria seems  to  play  a  role  in  etiology.  Chronic  endocarditis 
is  often  assigned  as  a  cause  of  chronic  renal  diseases ;  it  is 
probable,  however,  that  there  is  no  direct  causal  relationship, 
but,  rather,  that  the  factor  accountable  for  the  endocarditis 
also  excites  the  renal  inflammation. 

In  a  study  of  the  etiology,  the  occupation  of  the  patient 
must  be  investigated,  because  of  the  fact  that  exposure  over 
a  long  period  of  time  to  mercury,  turpentine,  carbolic  acid, 
tar,  naphthol,  glycerine,  oxalic  acid  and  sulphuric  acid  may 
cause  the  disease  in  question.    Exposure  to  great  heat  or  cold, 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  591 

as  in  the  case  of  glass  blowers,  iron  workers,  stokers  confined 
to  hot  eng^ine  rooms,  is  a  predisposing  factor. 

Almost  always  the  kidneys  are  found  enlarged.  It  is  to 
be  remembered  that  the  process  is  diffuse,  and  it  is  owing  to 
the  variable  degree  of  implication  of  the  different  structural 
units  of  the  kidney  that  various  types  have  been  described. 

The  leadings  type  is  the  large  white  kidney,  in  which  the 
renal  epithelium  is  chiefly  affected.  It  is  light  gray  in  color, 
with  prominent  stellate  veins.  The  capsule  strips  easily  and 
the  renal  substance  is  soft.  On  section  the  cortex  is  seen  to 
be  swollen,  and  may  be  as  wide  as  the  medulla,  instead  of 
about  one-third  of  its  width,  the  normal  proportion.  The 
color  on  section  is  grayish,  and,  in  some  instances,  minute 
reddish  dots  betray  the  areas  in  which  hemorrhages  have 
occurred.     The  pyramids  are  dark  in  color. 

Microscopically,  the  cells  of  the  tubules  are  swollen,  gran- 
ular, and  fatty.  In  some  the  nucleus  has  disappeared.  The 
lumen  of  the  tubule,  in  some  places,  is  diminished  by  the 
swollen  cells ;  in  other  parts  it  is  greater  than  normal,  because 
the  living  cells  have  disappeared.  Casts  of  various  kinds, 
erythrocytes  and  degenerated  epithelium,  are  found  in  the 
tubules.  Some  of  the  Malpighian  bodies  are  enlarged,  and 
the  epithelium  of  the  glomerules  and  Bowman's  capsule  are 
in  a  state  of  fatty  degeneration.  The  connective  tissue  be- 
tweeii  the  tubules  is  edematous,  and  areas  of  round  cell  infil- 
tration are  observed.  Small  hemorrhages  in  the  connective 
tissue  are  sometimes  seen. 

The  disease  begins  insidiously  and  progresses  slowly. 
The  symptoms  are  likely  to  be  vague,  and  not  in  the  least 
suggestive  of  serious  renal  disease.  The  patient  probably 
consults  the  physician  because  of  malaise,  poor  appetite,  dis- 
inclination to  do  his  usual  work,  and  fatigue  without  adequate 
cause.  Weakness  and  headache  may  be  the  first  symptoms 
noted.  The  importance  of  investigating  thoroughly  the  cause 
of  all  such  symptoms  cannot  be  urged  too  strongly,  because 
the  diagnosis  thus  may  be  established  long  before  the  obvious 
symptoms  and  signs  of  nephritis  appear. 

The  most  characteristic  evidence  of  the  disease  is  obtained 
by  an  examination  of  the  urine  which,  as  a  rule,  is  reduced  to 


592  DISEASES    OF   THE    KIDNEYS. 

one-third  the  normal  daily  quantity.  The  specific  gravity  is 
normal,  or  even  increased  during  most  of  the  course  of  the 
disease,  but  later  it  may  become  extremely  low  when  renal 
insufificiency  becomes  very  great,  on  account  of  failure  of  the 
renal  cells  to  excrete  urinary  solids.  A  low  specific  gravity 
of  a  urine,  with  diminution  of  the  quantity,  is  an  unfavorable 
sign.  In  the  absence  of  infection  of  the  bladder,  and  when 
uninfluenced  by  medication,  the  urine  is  acid ;  sometimes 
decidedty  so.  Albumin  is  present  in  large  amounts,  0.5  to  2 
per  cent,  by  weight  and  25  per  cent,  or  more  by  volume.  The 
urine  may  be  turbid  because  of  the  presence  of  urates. 
Hyaline  and  granular  casts  are  present  in  abundance,  and 
epithelial  and  waxy  casts  may  also  be  found.  During  an 
acute  exacerbation  erythroc3"tes  and  blood-casts  appear. 
Renal  epithelium  in  all  stages  of  degeneration  is  found  in 
large  quantities. 

There  is  probably  no  other  type  of  nephritis  in  which 
edema  is  present  to  such  a  degree,  although  early  in  the 
course  of  the  disease  it  is  absent.  As  a  rule,  it  is  observed 
first  simply  as  a  pufhness  about  the  eyes,  perhaps  even 
limited  to  the  lower  eyelids.  As  the  disease  progresses,  the 
entire  face  becomes  swollen  and  the  lines  of  expression  are 
obliterated,  and  finally  the  subcutaneous  tissue  of  the  entire 
body  becomes  greatly  edematous.  The  loose  areolar  tissue 
of  the  scrotum  and  penis  maj^  become  so  distended  with, fluid 
that  much  distress  is  caused  and  urination  interfered  with  to 
a  marked  degree.  Large  quantities  of  fluid  mav  accumulate 
in  the  peritoneal,  pleural,  and  pericardial  cavities,  greatly 
embarrassing  the  action  of  the  heart  and  lungs.  Edema  of 
the  mucous  membrane  of  the  gastrointestinal  tract  prevents 
the  digestion  and  absorption  of  food,  as  a  result  of  which 
weakness  and  anemia  occur. 

The  anemia  is  seldom  severe,  the  erythroc3'tes  are  rarely 
less  than  3,000,000  per  cmm.,  with  a  commensurate  loss  of 
hemoglobin.  The  pallor  of  the  skin  is  out  of  all  proportion  to 
the  intensit}^  of  the  anemia,  giving  the  patient  a  ver\^  character- 
istic wax-like  appearance.  This  pallor  is  due  to  a  marked 
hydremia  as  well  as  to  anemia.  The  majority  of  cases  ter- 
minate fatally  in  one  or  two  years.  In  some  instances  a 
rather  unexpected  change,   apparently   for  the   better,   takes 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  593 

place.  The  edema  vanishes,  the  urine  increases  in  amount; 
the  albuminuria  diminishes  to  a  very  small  quantity,  and  all 
casts,  except  a  few  hyaline  and  granular,  disappear.  This 
usually  indicates  the  transition  from  chronic  nephritis,  w^ith- 
out  induration,  to  chronic  nephritis  with  induration,  in  which 
event  the  course  of  the  disease  is  somewhat  lengthened,  but 
eventually  death  occurs  from  chronic  diffuse  nephritis. 

Unfortunately  no  remedies  exist  that  will  cure  chronic 
parenchymatous  nephritis,  but  this  does  not  mean  that  the 
mortality  rate  in  this  type  of  renal  disease  is  100  per  cent.  A 
few  cases  are  reported  in  which  the  inflammation  was  arrested 
and  regeneration  occurred  to  such  an  extent  that  the  patient 
became  entirely  well.  When  the  disease  is  due  to  recurrent 
infection  from  a  focus  elsewhere  in  the  body,  and  the  original 
focus  is  removed,  the  best  opportunity  is  afforded  for  com- 
plete recovery.  In  the  vast  majority  of  cases,  however,  the 
best  we  can  hope  to  accomplish  is  the  prolongation  of  life, 
with  as  much  freedom  from  distressing  symptoms  as  pos- 
sible. It  must  be  realized  that  the  ability  of  the  kidneys  to 
properly  functionate  is  diminished,  and  that,  therefore,  the 
patient  must  live  within  his  renal  efficiency;  the  demands 
made  upon  the  kidneys  must  be  greatly  reduced.  This  is 
done  by  regulating  the  daily  activities  of  the  patient  and 
arranging  his  diet  so  that  the  end-products  of  its  metabolism 
may  be  eliminated  with  ease,  and  are  non-irritant  in  their 
passage.  It  is  of  the  utmost  importance  to  avoid  intestinal 
toxemia. 

Obviously,  rest  is  an  important  part  of  the  treatment,  but 
in  a  disease  that  lasts  for  many  months,  strict  confinement  to 
bed  is  not  only  ill-advised,  but  may  be  actually  injurious  by 
its  monotony  and  the  consequent  depression  of  the  entire 
nervous  system.  On  the  other  hand,  experience  teaches  that 
rest  in  the  horizontal  position  relieves  the  kidneys,  as  shown 
by  the  diminished  quantity  of  albumin  in  the  urine  voided 
upon  arising  in  the  morning,  as  compared  with  the  quantity 
found  in  the  specimen  passed  upon  retiring.  The  aim  should 
be,  therefore,  to  obtain  as  much  rest  in  recumbenc}^  as  pos- 
sible. In  patients  with  little  or  no  edema,  and  not  more  than 
a  moderate  amount  of  albuminuria,  ten  to  twelve  consecutive 
hours  in  bed  should  be  prescribed ;  and  in  the  early  afternoon 


594  DISEASES    OF    THE    KIDNEYS. 

the  patient  should  spend  one  or  two  hours  in  recumbency. 
Physical  exertion  that  would  be  very  moderate  for  one  in 
health  is  to  be  regarded  as  excessive  in  chronic  parenchyma- 
tous nephritis.  Ascending  steps,  walking  long  distances  on 
level  ground,  and  going  up  hill  should  be  reduced  to  a  mini- 
mum, the  patient  being  instructed  to  use  a  conveyance  to  get 
about  from  place  to  place.  In  this  way  it  is  possible  for 
considerable  business  to  be  transacted  with  a  minimum  of 
physical  fatigue.  Standing  for  long  periods  must  be  avoided. 
When  the  urine  becomes  scanty  and  edema  increases,  abso- 
lute confinement  to  bed  becomes  necessary,  and  must  be  con- 
tinued until  the  edema  lessens  and  the  urine  increases  in 
amount.  Acute  exacerbations  are  common,  and  must  be 
treated  as  an  acute  nephritis. 

Prolonged  exposure  to  cold  and  wet  should  be  avoided. 
When  possible  the  patient  should  leave  a  cold,  wet  climate, 
and  live  in  a  locality  where  it  is  dry  and  warm.  The  warmth 
dilates  the  peripheral  vessels  and  increases  the  elimination 
through  the  skin.  In  such  a  climate  the  patient  is  enabled  to 
be  out-of-doors,  which  is  of  distinct  advantage.  Suitable 
winter  climate  may  be  found  in  southern  Texas,  southern 
California,  and  low  altitudes  in  Arizona  and  New  Mexico. 
Those  unable  to  secure  the  advantages  of  suitable  climate 
must  dress  warmly.  Flannels  should  be  worn  next  the  skin. 
On  cold  stormy  days  the  invalid  must  stay  indoors. 

In  order  to  keep  the  skin  active,  a  warm  cleansing  bath 
should  be  taken  daily.  Cold  baths  of  all  kinds  must  be 
avoided.  Sea  bathing,  because  of  the  low  temperature  of  the 
water  and  the  exertion  necessary,  must  be  strictly  forbidden. 
Sweating  should  be  induced  by  means  of  hot  baths,  as  de- 
scribed on  page  586.  The  frequency  of  the  sweat  baths  must 
depend  upon  the  condition  of  the  patient.  Weakness  follows 
their  use,  so  that  they  should  be  employed,  generally  speak- 
ing, but  once  or  twice  a  week,,  when  elimination  is  not  entirely 
satisfactory.  Turkish  baths  may  be  substituted  for  the  sweat 
baths.  In  acute  exacerbations  sweat  baths  must  be  used  daily 
as  in  acute  nephritis. 

Diet  is  one  of  the  essential  parts  of  treatment.  It  should 
be  arranged  so  that  the  proteins  are  just  sufiEicient  to  supply 
the  needs  of  the  body,  remembering  that  muscular  activity 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  595 

has  been  greatly  reduced.  The  bulk  of  the  food  should  be 
selected  from  the  carbohydrates  and  fats.  It  is  impossible  to 
g'ive  a  standard  of  protein  diet  that  will  be  applicable  to  all 
cases,  or  even  to  the  same  case  throughout  the  entire  course, 
since  the  functional  power  of  the  kidneys  and  gastrointestinal 
tract  varies  in  different  phases  of  the  disease,  and  also  because 
the  needs  of  the  organs  vary  from  time  to  time ;  the  quantity 
required  when  the  patient  remains  absolutely  quiet  in  bed 
will  be  less  than  when  he  is  going  about. 

When  the  urine  is  scanty  and  contains  a  large  amount  of 
albumin,  when  edema  is  very  much  in  evidence  and  symptoms 
of  uremia  are  present,  the  diet  is  restricted  to  8  ounces  (240 
mils)  of  skimmed  milk,  taken  at  intervals  of  four  hours 
between  8  a.m.  and  8  p.m.,  and  when  anasarca  is  present, 
absolutely  no  other  fluids  than  this  are  allowed.  As  improve- 
ment is  made,  crackers  or  zwieback  are  permitted  with  the 
milk,  and  gradually  the  diet  is  increased  by  the  addition  of 
eggs,  cooked  cereals,  toast,  butter  and  vegetables,  such  as 
rice,  potatoes,  barley,  hominy,  spinach,  green  beans  and  peas. 

It  is  estimated  that  a  minimum  of  40  to  50  Gms.  (1.28  to  1.6 
ozs.)  of  proteins  are  required  by  the  body  daily,  and  if  not 
supplied  by  the  food  the  proteins  of  the  body  will  be  utilized, 
causing  emaciation.  In  the  treatment  of  nephritis  the  pro- 
teins may  be  greatly  restricted  for  a  time,  but  as  soon  as  pos- 
sible the  minimum  physiological  amount  of  proteins  must  be 
supplied.  This  may  be  done  by  giving  increased  quantities 
of  milk.  Later  it  may  be  given  in  other  forms,  such  as  eggs, 
meats  and  fish,  but  the  daily  quantity  consumed  should  be 
kept  under  50  Gms.  (1.6  oz.).  The  following  list  will  give 
the  quantity  of  raw  foodstufifs  that  would  yield  50  Gms.  (1.6 
oz.)  of  protein  :6 

Hen  eggs    7 

Milk 1660  mils  P/^  qts. 

Lean   beef    220  Gms.  yVs  ozs. 

Ox    tongue    300     "  10 

*Lean  veal  260     "  8%  " 

*Calf's  liver  260  "  8%  " 

Lean  mutton   250  "  SVs  " 

*Lean   pork    .-. 240     "  8  " 


*  These  should  be  excluded  because  of  their  indigestibilitjr. 


596  DISEASES    OF   THE    KIDNEYS. 

Very  fat  bacon  3000  Gms.  100  ozs. 

Chicken  breast    250  "  8%  " 

Pigeon    210  "  7 

*Goose  320  "  IO2/3  " 

*Rabbit    200  "  6%  " 

*Venison   230  "'  7%  " 

Trout   260  "  8%  " 

Pike    260  "  8%  " 

*Herring  260  "  8%  " 

*Salmon    230  "  7%  " 

*Lobster 300  "  10 

Oysters    800  "  26 

Cooked  Boiled  Meats. 

Lean  beef  150  Gms.  5      ozs. 

*Lean  veal  190     "      6I/3    '■ 

Lean  mutton 160     "       5%    " 

*Lean  pork   175     "      5^^    " 

Chicken  breast  160     ''      oYs    " 

*Salmon 210     "      7]i    " 

Baked  or  Broiled  Meats. 

Roast  beef   200  Gms.  (fi/^  ozs. 

Beef   steak  200     "      6?^    " 

Stewed  beef   160     "      51/3    " 

*Roast  veal   200     "      6%    " 

Lamb  chop 220     "      7%    " 

An  adult  of  average  weight  will  require  about  2200 
calories  daily,  if  at  rest,  and  about  3000  if  working.  If  the 
patient  be  allowed  the  minimum  of  protein,  50  Gms.  (1.6  oz.) 
equivalent  to  200  calories,  the  remaining  calories  must  be  sup- 
plied from  the  fats  and  carbohydrates.  It  is  a  matter  of 
indifference  whether  the  white  or  the  dark  meats  are  allowed, 
the  important  thing  being  not  to  permit  more  than  will  sup- 
ply the  protein  needs  of  the  body.  The  same  is  also  true  of 
eggs.  Smoked  and  salt  meats,  and  fish,  condiments  and  meat 
extractives,  as  beef  tea,  etc.,  should  be  avoided.  Salt  should 
be  restricted,  and  when  edema  is  present  no  salt  whatever  is 
permissible.  The  amount  of  salt  consumed  by  the  average 
individual  is  much  in  excess  of  the  needs  of  the  body,  which 
is  about  1  or  2  Gms.  (15.4  to  30.8  grs.)  ;  when  edema  is  absent 
this  quantity  may  be  allowed. 


'These  should  be  excluded  because  of  their  indigestibility. 


CHRONIC    PARENCHYMATOUS    NEPHRITIS.  597 

The  moderate  use  of  tea  and  coffee  may  ])e  permitted, 
Unless  sleep  is  affected.  Alcohol  is  harmful.  As  nicotin  is 
a  poison  to  nerve  tissue  and  to  the  heart,  tobacco  should  be 
avoided  by  the  patient. 

Diuretics  which  act  chiefly  on  the  glomeruli,  stimulating 
them  to  increased  activity,  and  which  do  not  irritate  the 
epithelium  of  uriniferous  tubules,  should  be  used,  not  rou- 
tinely, but  as  necessary.  The  value  of  water,  milk  and 
lemonade  as  diuretics  should  be  kept  in  mind.  Potassium 
bitartrate  (cream  of  tartar),  15  to  30  grains  (0.9  to  1.9  Gms.) 
may  be  added  to  the  lemonade.  Infusion  of  digitalis,  1  to  4 
drams  (4  to  16  mils),  every  four  hours  is  often  of  great 
value.  Potassium  citrate,  15  to  30  grains  (0.9  to  1.9  Gms.), 
sometimes  seems  to  be  of  assistance. 

In  some  cases,  late  in  the  course  of  the  disease,  the  heart, 
hypertrophied  in  its  effort  to  meet  the  new  demands  thrown 
upon  it,  dilates,  causing  an  increase  in  the  amount  of 
edema,  and  it  is  especially  in  these  instances  that  the  effusions 
into  the  serous  cavities  take  place.  It  then  becomes  neces- 
sary to  prohibit  the  use  of  salt  in  the  food,  and  an  attempt  to 
carry  off  the  fluid  by  copious  bowel  movements  must  be 
made.  The  use  of  diuretics,  preferably  of  the  digitalis  group, 
is  demanded.  If  the  effusion  in  the  serous  cavities  increases 
in  amount,  and  causes  symptoms,  or  gives  evidence  by  phys- 
ical signs  of  embarrassed  action  of  the  heart  and  lungs,  the 
fluid  must  be  removed  by  aspiration. 

In  aspiration  of  the  pleural  cavity  the  skin  of  the  area  to 
be  tapped  must  be  washed  with  soap  and  water  and  dried; 
then  tincture  of  iodin  is  applied  and  allowed  to  remain  for 
a  few  minutes  before  being  removed  with  alcohol.  The  site 
selected  is  the  seventh  interspace  between  the  posterior 
axillary  line  and  the  scapula,  or  immediately  below  the  angle 
of  the  scapula,  it  having  been  determined  beforehand,  by 
physical  examination,  that  the  lung  is  pushed  away  from  that 
locality.  After  the  apparatus  has  been  sterilized,  it  is  tested 
to  see  that  it  works  properly.  It  consists  of  a  bottle,  a  pump 
for  exhausting  the  air  from  the  bottle,  and  a  trocar  and 
canula  or  needle,  with  rubber  tubing  to  connect  the  canula 
and  the  pump  with  the  bottle.     The  trocar  and   canula,  or 


598  DISEASES   OF   THE   KIDNEYS.- 

needle,  should  be  at  least  6  inches  (15.2  cm.)  long  with  a 
diameter  of  not  more  than  y^  of  an  inch  (3.1  mm.).  The 
entrance  of  air  into  the  bottle  through  the  needle  is  prevented 
by  clipping  the  connecting  tube  with  a  hemostat.  The  air  is 
then  exhausted  from  the  bottle.  The  needle  is  held  in  the 
hand  in  such  a  manner  that  the  proximal  end  is  in  contact  with 
the  center  of  the  palm,  while  the  index  finger  rests  on  the  shaft 
about  3  inches  (7.6  cm.)  back  from  the  point.  "With  firm  pres- 
sure the  needle  is  pushed  into  the  interspace  until  the  tip  is 
within  the  pleural  cavity.  The  hemostat  is  removed  from  the 
tube  and  the  liquid  allowed  to  flow  slowly  into  the  bottle.  It 
is  not  necessary  to  draw  off  the  entire  quantity  of  the  fluid, 
two-thirds  of  the  quantity  being  enough.  The  remainder  is 
usually  quickly  absorbed.  Faintness  and  vertigo  occurring 
during  th^  tapping,  unless  due  to  psychic  shock,  indicate 
immediate  withdrawal  of  the  needle.  If  severe  cousrhinsf  be- 
gins  after  considerable  of  the  fluid  has  been  withdrawn,  the 
operation  must  be  discontinued.  A  collodion  dressing  is  suffi- 
cient to  close  the  wound  made  by  the  needle. 

The  accumulation  of  a  large  quantity  of  fluid  in  the  peri- 
toneal cavity  is  likely  to  cause  passive  congestion  of  the  kid- 
neys by  the  pressure  of  the  fluid  on  the  renal  veins.  This 
would  be  indicated  by  a  diminishing  quantity  of  urine  con- 
taining microscopic,  and,  rarely,  macroscopic  blood.  The 
upward  pressure  exerted  upon  the  diaphragm  is  likel}^  to 
interfere  seriously  with  the  action  of  the  heart  and  lungs.  If 
the  fluid  does  not  diminish  in  a  short  time  as  a  result  of 
measures  directed  towards  the  relief  of  general  edema,  the 
fluid  must  be  relieved  by  aspiration,  as  has  been  described, 
or  by  a  trocar  and  canula,  as  follows :  The  skin  over  the 
abdomen  is  prepared  as  was  advised  for  thoracentesis.  The 
sterile  trocar  and  canula  are  held  in  the  hand,  so  that  the 
proximal  end  of  the  instrument  is  in  the  palm  of  the  hand 
and  tip  of  the  index  finger  3  or  4  inches  (7.6  or  10.1  cm.)  back 
from  the  point  of  the  instrument,  which  is  plunged  through 
the  abdominal  wall  in  the  midline,  equidistant  from  the  um- 
bilicus and  pubes.  A  small  incision  through  the  skin  may  be 
made  at  the  site  selected  before  inserting  the  trocar.  The 
urinary  bladder  should  be  empty. 


CHRONIC   INTERSTITIAL  NEPHRITIS.  599 

The  fluid  should  be  withdrawn  slowly,  and  as  its  level 
falls,  a  many-tailed  binder  should  be  applied  so  as  to  prevent 
too  great  reduction  in  intra-abdominal  pressure.  Death  has 
followed  the  too  rapid  evacuation  of  a  peritoneal  effusion 
through  a  large  canula. 

In  some  instances  after  removal  of  fluid  there  is  no  recur- 
rence, but  not  infrequently  there  is  a  reaccumulation,  and 
repeated  tappings  are  necessary,  as  the  transudate  reaccumu- 
lates  from  time  to  time. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Chronic  interstitial  nephritis  is  characterized  by  a  great 
increase  in  the  connective  tissue  of  the  kidney  with  a  lesser 
degree  of  fibrosis  affecting  the  glomerules  and  the  cells  of  the 
tubules.  There  is  always  an  associated  cardiac  hypertrophy, 
and  a  variable  degree  of  arteriosclerosis. 

In  the  great  majority  of  cases  no  causative  factor  can  be 
assigned.  The  disease  is  insidious,  of  long  duration,  and  so 
many  causal  factors  may  be  at  work,  that  it  is,  as  a  rule, 
impossible  to  select  one  and  ascribe  to  it  the  production  of 
the  disease. 

Undoubtedly  the  disease  follows  recurring  acute  nephritis. 
In  the  course  of  an  acute  infectious  disease  a  more  or  less 
severe  nephritis  develops  with  or  without  dropsy,  runs  a 
favorable  course,  but  leaves  behind  a  slight  intermittent  albu- 
minuria which  is  overlooked  or  neglected,  until  after  a  time 
unmjstakable  signs  of  chronic  nephritis  make  their  appear- 
ance. The  disease  may  have  its  origin  also  in  the  nephritis 
of  pregnancy. 

Among  the  infectious  diseases  capable  of  initiating  chronic 
nephritis  should  be  mentioned  influenza.  It  is  very  likely 
that  recurring  infection  of  the  kidneys  with  an  organism  of 
low  virulence  from  a  focus  in  the  tonsils,  sinuses,  or  about 
the  teeth,  may  account  for  a  larg-e  number  of  cases  of  this 
disease. 

A  subdivision  of  chronic  interstitial  nephritis — arterio- 
sclerotic kidney — is  made  by  many  writers.  Such  a  sub- 
division has  little  value  clinically,  but  is  interesting  only 
because  it  draws  attention  to  the  fact  that  the  cause  which 
produced  the  nephritis  was  also  very  active  in  producing  vas- 


600  DISEASES   OF   THE   KIDNEYS. 

cular  and  cardiac  disease.  There  is  still  considerable  discus- 
sion over  the  relationship  of  chronic  interstitial  nephritis  and 
arteriosclerosis.  Senator  says  the  relations  existing  between 
induration  of  the  kidneys  and  arteriosclerosis  are  of  a  triple 
character:  (1)  As  a  result  of  certain  noxious  agents  arterio- 
sclerosis may  be  the  primary  affection  and  bring  about  indu- 
ration of  the  kidneys,  forming  the  so-called  arteriosclerotic 
induration  of  the  kidney  or  contracted  kidney.  (2)  Con- 
versely, induration  may  result  from  chronic  interstitial  neph- 
ritis^ and  later,  on  account  of  the  cardiac  hypertrophy  and 
associated  increase  in  the  arterial  tension,  cause  a  vascular 
sclerosis.  (3)  The  two  conditions  may  develop  independently 
of  one  another  from  the  same  cause. 

Alcohol  is  an  important  etiological  factor.  There  is  prob- 
ably little  action  by  alcohol  as  such  on  the  renal  tissue.  The 
main  influence  is  through  its  action  on  the  gastrointestinal 
tract  and  liver,  causing  disorders  of  digestion  and  abnormali- 
ties of  metabolism,  as  a  result  of  which  toxic  substances  are 
elaborated,  which  in  their  elimination  through  the  kidney 
excite  the  inflammation.  Alcohol  produces  cirrhosis  of  the 
liver,  and,  in  association,  this  condition  is  found  in  almost 
every  instance  of  induration  of  the  kidneys.  Excessive  beer 
drinking  over  a  long  period  of  time  causes  interstitial  neph- 
ritis, largely  through  the  effect  upon  the  circulatory  apparatus 
of  the  kidneys. 

Long-continued  gastrointestinal  indigestion,  from  any 
cause,  may  result  in  chronic  renal  disease.  The  same  is  true 
of  certain  metabolic  disorders,  such  as  gout  and  diabetes. 
Chronic  intoxication  with  certain  chemicals,  notably  lead, 
result  in  hardening  of  the  kidneys. 

The  association  of  chronic  interstitial  nephritis  and  heart 
disease  is  very  close.  Usually  the  same  cause  produces  both. 
Occasionally  the  disease  of  the  kidney  is  secondary  to  the 
disease  of  the  heart,  and  is  the  result  of  chronic  passive  con- 
gestion, just  as  cirrhosis  of  the  liver  (cardiac  cirrhosis)  is 
observed  in  many  instances. 

The  kidneys  in  chronic  interstitial  nephritis  are  small  and 
firm,  with  a  rough  surface,  upon  which  ma^^  be  found  one  or 
more  cysts  of  varying  size  containing  usually  a  pale,  clear, 
straw-colored  liquid.     The  capsule  is  thickened,  strips  with 


CHRONIC    INTERSTITIAL    NEPHRITIS.  601 

some  difficulty  and  adheres  to  the  cortex  so  firmly  in  places 
that  this  substance  is  torn  in  the  stripping  of  the  capsule. 
On  section  the  kidney  tissue  is  resistant  to  the  knife.  Because 
of  the  diminution  of  the  renal  substance,  the  space  in  which 
the  pelvis  lies  appears  unusually  large,  and  is  often  well  filled 
with  adipose  tissue.  The  cortex  is  often  much  narrowed, 
often  being  only  2  to  3  mm.  (0.06  to  0.09  inch)  in  width.  The 
striae  are  seen  with  difficulty.  The  pyramids  appear  larger 
than  normal,  but  are  not  actually  so.  Owing  to  the  atrophy 
of  the  cortex  the  bases  of  some  of  the  pyramids  are  almost 
immediately  under  the  capsule.  The  blood-vessels  are  rigid, 
and  gape  on  section. 

On  microscopic  study  some  of  the  glomeruli  are  enlarged, 
this  change  probably  being  of  compensatory  character.  In 
others  the  capillary  loops  are  so  thick  that  they  are  imper- 
meable to  blood.  The  capsule  about  some  of  the  glomeruli 
is  very  greatly  thickened,  and  filled  with  a  hyaline  mass  show- 
ing complete  destruction. 

Some  of  the  tubules  are  enlarged  through  compensatory 
hypertrophy,  others  dilated  as  the  result  of  constriction  of 
their  distal  lumen,  and  still  others  are  atrophied.  The  cells 
of  some  of  the  tubules  present  evidences  of  degeneration. 
The  protoplasm  is  very  granular,  and  contains  hyalin  and 
fat  droplets. 

The  connective  tissue  outside  the  glomeruli,  and  between 
the  tubules,  is  increased  in  amount.  In  its  meshes  the  blood- 
vessels, obliterated  glomeruli,  and  traces  of  tubules  become 
very  closely  arranged,  because  of  the  disappearance  of  so 
many  structures  which  were  there  before.  There  is  more  or 
less  round  cell  infiltration. 

In  addition  to  the  pathologic  changes  in  the  kidneys, 
hypertrophy,  and  sometimes,  dilatation  of  the  heart,  chiefly 
of  the  left  ventricle,  are  found.  The  heart  muscle  usually 
shows  some  evidence  of  degeneration.  The  blood-vessels  are 
thickened  and  dilated,  and  their  elasticity  is  diminished.  Ex- 
treme arteriosclerosis  and  atheroma  occur  sometimes  in 
association  with  chronic  interstitial  nephritis. 

It  is  one  of  the  unfortunate  characteristics  of  this  disease 
that  for  a  long  time  after  the  pathologic  changes  have  begun 
in  the  kidney,  no  symptoms  occur.     Were  it  otherwise,  the 


602  DISEASES    OF    THE    KIDNEYS. 

disease  could  be  detected  in  a  much  earlier  stage.  By  the 
time  symptoms  are  noted,  the  disease  is  usually  well  ad- 
vanced. The  early  symptoms  are  so  vague  that,  unless  a 
thorough  study  of  the  patient  is  made,  the  real  cause  of  the 
symptoms  may  be  overlooked.  Among  the  earliest  clinical 
manifestations  are  anorexia,  loss  of  the  power  of  concentra- 
tion, and  mental  and  physical  fatigue  after  but  moderate 
effort.  Such  symptoms  are  apt  to  be  ascribed  to  overwork 
instead  of  to  the  true  cause,  namely,  nephritis.  Sometimes 
headache  and  momentary  attacks  of  vertigo  are  the  symptoms 
for  which  the  physician  is  consulted.  When  a  blood-pressure 
observation  is  made,  using  a  sphygmomanometer,  the  systolic 
pressure  is  found  to  be  170  mm.  or  higher.  In  some  instances 
in  which  slight  symptoms  are  complained  of,  the  blood-pres- 
sure has  been  found  to  be  250  mm. ;  in  one  instance  300  mm., 
and  in  another  320  mm.  Patients  may  pay  no  attention  to 
the  slight  symptoms,  and  the  first  intimation  of  serious  trou- 
ble may  be  cerebral  hemorrhage  or  acute  uremia. 

It  is  impossible  to  select  a  symptom-complex  as  represen- 
tative of  a  disease  where  the  symptomatology  is  so  varied. 
Some  cases  will  present  symptoms  that  result  from  renal 
toxemia;  others  appear  to  present  more  the  picture  of  a 
myocardial  degeneration. 

The  urine  is  increased  in  amount,  usually  light  in  color, 
and  of  low  specific  gravity  (1005  to  1012).  There  is  very 
little  sediment  deposited,  and  on  examination  under  the 
microscope  a  very  few  hyalin  casts  are  the  only  abnormali- 
ties. Sometimes  they  are  found  only  after  a  prolonged 
search.  Albumin  is  present  in  very  small  quantity  and  is 
not  constant.  It  is  often  absent  in  specimens  voided  upon 
arising  in  the  morning,  and  sometimes  for  days  and  weeks 
at  a  time  it  may  be  absent  from  all  specimens  examined.  It 
is,  therefore,  important  to  avoid  the  mistake  of  eliminating 
the  possibility  of  interstitial  nephritis  upon  the  findings  of 
but  one  urinalysis,  in  the  absence  of  albuminuria. 

Cardiac  hypertrophy  is  constantly  associated  with  indu- 
rated kidneys,  even  when  no  symptoms  are  manifest.  At 
times  the  hypertrophy  is  very  marked.  The  apex  beat  is  dis- 
placed to  the  left  and  sometimes  downward  as  well,  and  is 
usually  well  felt,  unless  dilatation  has  occurred.     The  mus- 


CHRONIC    INTERSTITIAL    NEPHRITIS.  603 

ctilar  element  of  the  first  sound  is  increased.  The  aortic 
second  sound  is  accentuated,  and  sometimes  is  very  loud  and 
ringing.  In  some  cases  a  systolic  murmur,  due  to  mitral 
insufficiency,  is  audible  at  the  apex,  and  may  or  may  not  be 
transmitted  to  the  left  axilla.  In  the  late  stages  pericardial 
friction  rubs  are  sometimes  heard.  The  superficial  arteries 
are  found  to  be  much  thickened,  hard,  and  often  tortuous. 
The  radial  pulse  is  hard  and  sometimes  incompressible.  Pal- 
pation of  the  pulse  is  not  always  a  safe  guide  in  studying  the 
pressure.  A  pulse  that  is  seemingly  compressed  with  mod- 
erate ease  may  show  on  the  blood-pressure  instrument  a  read- 
ing of  200  mm.,  especially  if  the  pulse  pressure  be  increased. 
The  reverse  is  also  sometimes  true. 

Dyspnea  on  exertion  is  a  common  symptom  somewhat 
late  in  the  disease,  and  is  dependent,  in  some  instances,  en- 
tirely on  the  condition  of  the  heart.  Toxic  dyspnea,  entirely 
independent  of  myocardial  disease,  is  frequently  observed.  It 
may  take  the  form  of  sudden  attacks  of  suffocative  feelings 
occurring  during  the  night,  awakening  the  patient  from  sleep, 
causing  him  to  sit  up  in  bed,  or  even  to  arise  and  sit  in  a  chair 
at  the  window.  Such  an  attack  may  last  but  a  few  minutes, 
and  recur  one  or  more  times  during  the  night ;  or,  it  may  last 
for  hours,  during  which  the  physical  discomfort  is  associated 
with  considerable  mental  suffering.  Cheyne-Stokes  breathing 
is  an  extremely  common  phenomenon  late  in  the  disease,  and 
is  of  bad  prognostic  significance,  as  it  indicates  a  pronounced 
degree  of  toxemia.  Usually  it  is  manifested  a  few  months 
prior  to  death,  but  not  uncommonly  it  may  recur  through  one 
or  more  years.  Often  the  patient  is  unconscious  of  this 
peculiar  type  of  respiration  and  feels  very  comfortable.  Some 
patients  are  very  much  distressed  by  its  presence.  The 
paroxysms  of  Cheyne-Stokes  breathing  are  very  likely  to 
occur  during  the  night. 

Retinal  changes  may  be  detected  in  the  great  majority  of 
instances  of  chronic  interstitial  nephritis,  sometimes  produc- 
ing almost  complete  blindness,  and  sometimes  not  affecting 
the  sight  at  all.  The  commoner  changes  in  the  retina  are 
whitish  or  yellowish  patches,  hemorrhages  and  diffuse  retinal 
opacity  from  edema.  The  arteries  are  thickened  and  the 
veins  are  enlarged. 


604  DISEASES    OF    THE    KIDNEYS. 

Uremia,  either  acute  or  chronic,  is  very  commonly  ob- 
served in  the  terminal  stages  of  the  disease.  The  first  evi- 
dence of  acute  uremia  may  be  a  clonic  convulsion  of  great 
severity  lasting  a  few  minutes,  after  which  consciousness  is 
rapidly  regained,  followed  for  a  short  time  by  slight  mental 
confusion  or  a  somewhat  dazed  state ;  or,  instead  of  regain- 
ing consciousness  after  the  convulsion,  the  patient  may  be- 
come comatose  and  die.  Sometimes  the  convulsions  are 
preceded,  for  a  few  hours  or  -a  day  or  two,  by  suggestive  pre- 
monitory disturbances  such  as  severe  headaclie,  nausea, 
vomiting  and  restlessness. 

In  chronic  uremia  convulsions  are  less  common.  The 
chief  symptoms  may  be  drowsiness,  or  restlessness  and 
insomnia,  headache,  nausea  and  A'omiting  after  eating  or 
drinking,  or  sometimes  produced  by  the  mere  sight  of  food. 
Partial  palsies  of  various  muscle  groups  are  often  observed. 
Delirium  may  occur,  and  last  for  daA^s. 

It  is  evident  that  in  dealing  with  a  disease  of  the  kidneys, 
so  insidious  and  at  the  same  time  so  serious,,  that  the  victim 
may  be  stricken  with  a  fatal  attack  of  uremia,  any  procedure 
that  discovers  the  functional  capacity  of  those  organs  is  of 
the  utmost  importance.  A  number  of  tests  are  now  being 
employed,  no  one  alone  being  sufftcient.  As  the  function  of 
the  kidney  is  a  complex  one,  carried  on  by  various  highly 
specialized  units,  it  is  not  surprising  to  learn  that  various 
tests  must  be  employed  in  the  study  of  renal  function.  The 
tests  that  are  of  practical  value  are  the  phenolsulphoneph- 
thalein  test,  the  nephritic  diet  test,  and  the  estimation  of  the 
blood  content  of  uric  acid,  urea,  and  creatinin. 

The  phenolsulphonephthalein  test  is  very  frequenth'  and 
extensively  used  at  the  present  time.  It  was  devised  by 
Rowntree  and  Geraghty,'''  and  depends  upon  the  injection  into 
the  tissues  of  a  dyestufif  which  is  eliminated  rapidlv  by  the 
normal  kidneys,  and  can  be  easily  estimated  quantitatively  in 
the  urine.  It  is  non-irritative,  and  does  no  harm  to  the 
kidneys. 

The  method  of  application  is  as  follows :  The  patient  is 
instructed  to  empty  the  bladder,  and  is  given  6  to  8  ounces 
(180  to  240  mils)  of  water  to  drink.  Then  1  mil  (16  m.)  of 
the  dyestuft,  which  can  be  obtained  in  sterile  ampoules,  is 


CHRONIC    INTERSTITIAL    NEPHRITIS.  605 

injected  snbcutaneously  into  the  arm  or  other  convenient  part 
of  the  body.  Normally  ten  minutes  are  required  fc^-  the 
elimination  of  the  substance  to  begin.  One  hour  and  ten 
minutes  after  the  injection  the  bladder  is  emptied  and  the 
entire  amount  of  urine  voided  is  saved.  One  hour  after  this 
specimen  is  voided  the  bladder  is  again  emptied,  and  the 
entire  quantity  saved.  These  specimens  separately  are  meas- 
ured, made  strongly  alkaline  by  the  addition  of  25  per  cent, 
sodium  hydroxid,  and  the  quantities  brought  up  to  1000  mils 
(1  qt.)  by  the  addition  of  water.  Comparison  is  made  in 
a  Duboscq  or  Hellige  colorimeter  with  a  standard  consisting 
of  3  mg.  (^0  gr.)  of  phenolsulphonephthalein  in  1000  mils  (1 
qt.)  of  distilled  water.  Each  mil  of  the  dyestufT  in 
the  ampoule  contains  6  mg.  (Y^q  gr.).  Since  the  volume  of 
each  urine  sample  is  the  same  as  that  of  the  standard,  the 
percentage  elimination  of  phenolsulphonephthalein  in  each 
may  be  easily  calculated  as  follows :  Reading  of  urine  :  Read- 
ing of  the  standard  : :  100 :  X.  The  amount  of  the  drug  elimi- 
nated normally  is  40  to  60  per  cent,  for  the  first  hour,  and  20 
to  25  per  cent,  during  the  second  hour,  or  a  total  of  60  to  85 
per  cent,  .for  the  two  hours. 

The  study  of  the  quantity  and  of  the  specific  gravity  of 
day  and  night  specimens,  according  to  the  method  of  Mosen- 
thal,^  sometimes  referred  to  as  the  nephritic  test  diet,  is  of 
value.  The  patient  is  ordered  to  eat"  three  full  meals  a  day 
and  to  write  down  the  approximate  quantities ;  for  example, 
one  cup  of  coffee,  two  slices  of  toast,  two  tablespoonfuls  of 
rice,  in  order  to  be  certain  that  the  diet  for  the  day  contains 
a  sufficient  quantity  of  the  diuretic  materials  of  ordinary  food 
to  make  an  adequate  demand  on  the  kidney.  The  urine  must 
be  collected  punctually  every  two  hours  from  8  a.m.  to  8  p.m., 
and  a  12-hour  specimen  from  8  p.m.  to  8  a.m.  is  also  taken. 
No  solid  food  or  fluid  of  any  kind  must  be  taken  between 
meals,  and  especial  care  must  be  observed  that  nothing  of  any 
kind  is  eaten  or  drunk  during-  the  night,  and  that  the  night 
specimen  is  completed  before  breakfast  is  touched.  The  vol- 
ume in  cubic  centimeters  and  the  specific  gravity  of  each 
specimen  are  determined.  After  each  meal  there  is  normally 
an  increase  in  the  quantity  of  urine,  with  a  wide  variation  of 
the  specific  gravity  (about  10  points)  and  a  small  quantity  of 


606  DISEASES    OF   THE   KIDXEYS. 

urine,  400  mils  (13.3  f5),  or  less,  between  8  p.m.  and  8  a.m., 
with  high  specific  gravity.  In  most  normal  individuals  the 
urinary  output  is  about  400  mils  (13.3  fo)  less  than  the 
intake.  - 

The  kidney  expresses  its  diminished  power  to  functionate 
by  a  fixation  of  its  concentration.  The  evidence  of  renal 
functional  impairment  consists  of  slight  variation  in  the 
quantity  and  specific  gravity  of  the  two-hourly  specimens  and 
an  increase  over  400  mils  (13.3  i'^)  with  little  change  in  the 
specific  gravity  of  the  twelve-hour  specimen. 

The  value  of  the  study  is  increased  if  the  chlorid  and 
nitrogen  excretion  for  the  twenty-four  hours  is  also  estimated. 

Much  valuable  information  may  be  gained  from  a  study 
of  the  concentration  in  the  blood  of  uric  acid,  urea  and  creat- 
inin.  Uric  acid  is  least  readily,  and  creatinin  most  readily 
eliminated  by  the  kidne3's,  urea  occupying  in  this  respect  a 
position  midway  between  the  two.  The  studies  of  Chase  and 
Myers^  show  that  many  earty  cases  of  nephritis,  probably  of 
the  interstitial  t\'pe,  give  blood-pictures  in  which  the  essential 
feature  is  the  high  uric  acid  content.  The  urea  and  creatinin 
are  frequently  normal,  though  sometimes  appreciably  in- 
creased. As  the  condition  of  the  cases  of  this  type  becomes 
more  scA'ere,  the  retention  of  urea  increases,  until  the  picture 
is  that  of  the  preceding  group.  If,  on  the  other  hand, 
the  case  goes  on  to  a  fatal  termination,  the  retention  of 
uric  acid  and  urea  is  followed  by  that  of  creatinin,  the  con- 
centration of  which  may  reach  twenty  times  the  normal.  As 
a  prognostic  test  the  blood  creatinin  has  been  found  of  very 
great  value. 

The  normal  concentration  of  uric  acid  is  1  to  2  mg.  (%4 
to  %2  gr-)j  urea  12  to  17  mg.  (%6  to  ^  gr.)  and  creatinin  1 
to  2  mg.  (%4  to  %2  gr.)  per  100  mils  (3.3  f^)  of  blood. 

The  technic  of  these  tests,  as  employed  by  Myers,  Fine 
and  Lough, 10  is  as  follows : 

Uric  Acid.  Ten  mils  (^/i  f^)  of  a  mixture  of  blood 
and  potassium  citrate  are  pipetted  into  a  casserole  of 
about  275  mils  (12.5  f^)  capacity  and  approximately  5  vol- 
umes of  hundredth  normal  acetic  acid  added.  The  mixture  is 
heated  over  a  water  bath,  and  finally  brought  to  a  boil  over  a 
free  flame,  stirring  continuously.     About  4  mils  (64.8  m.)  of 


CHRONIC    INTERSTITIAL    NEPHRITIS.  607 

fairly  thick  alumina  cream*  are  added  with  continuous  stir- 
ring- for  a  few  minutes.  The  sides  of  the  dish  are  washed 
down  from  time  to  time  with  hot  water,  and  the  mixture  then 
filtered  through  a  hardened  filter  paper.  The  coagulum  is 
returned  to  the  casserole  with  about  150  mils  (5  f,'))  of  hot 
water,  heated  and  filtered  through  the  same  paper.  The  com- 
bined filtrates  are  evaporated  to  1  or  2  mils  (16  or  32.4  m.) 
(the  material  should  be  protein-free)  and  transferred  to  a  15 
mils  (0.5  fo)  conical  centrifuge  tube,  washing-  the  casserole 
with  two  or  three  small  portions  of  hot  water,  but  keeping 
the  volume  at  or  below  10  mils  (2.7  fo).  About  15  drops  (1 
mil)  of  ammoniacal-silver-magnesium  mixturef  are  now 
added,  the  tube  shaken  and  placed  in  a  cool  place  (refriger- 
ator) for  about  fifteen  minutes  to  allow  for  the  precipitation 
of  the  purins.  The  tube  is  centrifuged,  the  supernatant  liquid 
decanted  off  and  allowed  to  rest  in  an  inverted  position  for 
about  five  minutes.  The  tip  of  the  tube  is  then  wiped  with 
filter  paper  and  the  ammonia  allowed  to  volatilize,  this  change 
being  facilitated  with  suction. 

For  the  development  of  the  color  prepare  a  100  mils  (3.3 
fj)  graduated  cylinder  for  the  standard  and  a  50  mils  (1.6 
f^)  cylinder  for  the  unknown.  Five  mils  of  the  uric  acid 
standard^    (5    mils  ^  1    mg.    of   uric    acid)    are    pipetted   into 


*  Alumina  Cream. — Prepare  by  precipitating  an  8  per  cent,  solution  of 
aluminum  acetate  in  acetic  acid  with  sodium  bicarbonate,  carefully  washing 
with  a  large  volume  of  distilled  water  by  decantation  several  times,  then 
filtering. 

t  Ammoniacal-silver-magnesium  solution  is  prepared  by  mixing  70  mils 
(2.3  f5)  of  3  per  cent,  silver  nitrate  solution,  30  mils  (1  fS)  of  mag- 
nesia mixture  and  100  mils  (3.3  i^)  concentrated  ammonia.  Any  turbidity 
which  may,  develop  is  filtered  off.  Magnesia  mixture  is  prepared  by  dis- 
solving 35  Cms.  (1.1  fo)  magnesium  sulphate  and  70  Gms.  (2.2  fB) 
ammonium  chlorid  in  280  mils  (9.3  fj)  distilled  water,  and  then  adding 
140  mils  (4.6  f5)  concentrated  ammonium  hydroxid. 

t  The  standard  tiric  acid  solution  is  prepared  as  follows :  Dissolve  9 
Gms.  (138.9  grs.)  pure  crystallin  hydrogen  disodium  phosphate  and  1  Gm. 
(15.4  grs.)  dihydrogen  sodium  phosphate  in  200  to  300  mils  (6.6  to  10  fj) 
hot  water.  Filter  and  make  up  to  500  mils  (16.6  f3)  with  hot  water.  Pour 
this  warm  clear  solution  on  200  mg.  (1000  mils)  uric  acid,  suspended  in  a 
few  cubic  centimeters  of  water  in  a  liter  (quart)  volumetric  flask.  Agi- 
tate until  completely  dissolved.  Add  at  once  exactly  1.4  mil  (23.3  ;;/.) 
glacial  acetic  acid.  Make  up  to  1  liter  (quart),  mix  and  add  5  mils  (1.3f3) 
chloroform.  Five  mils  of  this  solution  are  equivalent  to  1  mg.  uric  acid. 
The  solution  should  be  freshly  prepared  every  two  months. 


608  DISEASES    OF    THE    KIDNEYS. 

the  ICX)  mils  (3.2  i^)  cylinder.  To  the  .standard  are  added  2 
drops  (ys  mil  J  of  5  per  cent,  potassium  cvanid,  2  mils  {32A 
m.)  of  Folin-Macallum  reagent*,  20  mils  (5.3  foj  of  satu- 
rated (22  per  cent.)  sodium  carbonate,  and,  in  about  one 
minute,  water  to  the  100  mils  (3.3  if^)  mark.  To  the  pre- 
cipitate in  the  centrifuge  tube  are  added  1  or  2  drops  (^o  or 
Yi  mil)  of  the  potassium  cvanid,  2  mils  (32.4  m.)  of  the 
Folin-Macallum  reagent  and  15  to  20  mils  (4  to  5.3  fo)  of  the 
standard  sodium  carbonate,  depending  on  whether  the  color 
is  subsequently  diluted  to  50  or  100  mils  (1.6  or  3.3  f5).  After 
forty  to  sixty  seconds  dilute  with  water  until  the  intensity 
of  the  color  is  similar  to  the  standard,  and  then  match  in  the 
Duboscq  colorimeter.  The  prism  of  the  standard  may  be  set 
conveniently  at  the  10  mm.  mark. 

Urea.  Into  a  test-tube  (of  such  size  that  it  will  just  slip 
into  a  100  mils  {Z.Z  i"^)  cylinder)  are  introduced  1  mil  (16  m.) 
of  10  per  cent,  urease  solution,  or  about  0.1  Gm.  (1.5  grs.)  of 
the  dry  enzyme,  and  then  1  to  2  mils  (16  to  32.4  m.)  of  water. 
Two  mils  of  blood  are  now  added  with  an  Oswald-Folin 
pipette  and  the  tube  incubated  in  a  beaker  of  water  at  50°  C. 
(122°  F.)  for  about  one-half  hour.  At  the  end  of  this  time 
3  to  4  drops  (0.18  to  0.24  mils)  of  capr}iic  alcohol  or  1  mil  of 
amyl  alcohol  are  added  to  prevent  foaming  in  subsequent 
aeration.  Into  a  100  mils  {3.3  i"^)  graduated  cylinder,  with- 
out lip,  are  added  15  mils  (0.5  f5)  of  distilled  water  and  2 
drops  (0.12  mils)  of  10  per  cent,  hydrochloric  acid.  This  is 
now  closed  with  a  two-hole  stopper  having  a  glass  tube  pass- 
ing nearlv  to  the  bottom  of  the  grraduate.  The  tube  is  sealed 
at  the  lower  end,  but  contains  a  number  of  small  holes  to 
aid  in  the  complete  absorption  of  the  ammonia.  To  the  test- 
tube  containing  the  digested  blood  an  equal  volume  of  satu- 
rated sodium  carbonate  is  carefully  added,  the  solution  be- 
ing allowed  to  run  underneath  the  blood.  The  tube  is  now 
immediately  inserted  in  a  100  mils  (3.3  f5)  cylinder  and 
a  two-hole  stopper  is  used  containing  one  glass  tube,  which 


*  Folin-Macallum  reagent  is  prepared  by  boiling  100  Gms.  (3.2  fj) 
sodium  tungstate,  20  mils  (5.3  fS)  concentrated  hydrochloric  acid  and  30 
mils  (1  £3)  85  per  cent,  phosphoric  acid  in  750  mils  (25  fB)  distilled  water 
for  two  hours,  preferablj^  under  a  reflex  condenser,  and  then  making  up  to 
1000  mils  {Z:i2  £5)  with  water. 


CHRONIC    INTERSTITIAL    NEPHRITIS.  609 

passes  nearly  to  the  bottom  of  the  tube.  This  is  now  con- 
nected on  one  side  with  a  wash  bottle  containing  dilute  sul- 
phuric acid,  and  on  the  other  with  the  graduated  cylinder 
containing  the  dilute  acid  for  the  absorption  of  the  ammonia. 
The  ammonia  of  the  blood  is  now  transferred  to  the  cylinder 
containing  the  weak  acid,  by  vigorous  aeration  for  twenty  to 
thirty  minutes.  At  the  end  of  this  time  the  outfit  is  discon- 
nected and  nesslerization  carried  out  in  the  graduated  cylin- 
der, dilution  being  made  according  to  the  amount  of  ammonia 
present. 

Into  a  volumetric  flask  of  100  mils  (3.3  i^)  capacity,  if  the 
Duboscq  colorimeter  is  to  be  used,  are  pipetted  5  mils  (1.3 
f.S)  of  ammonium  sulphate  or  ammonium  chlorid  solution 
containing  1  mg.  (5  mils)  of  nitrogen.*  Fifty  to  60 
mils  (1.6  to  2  fo)  of  distilled  water  are  added.  Ten  mils  (2.7 
fo)  of  modified  Nessler'si  solutionf  are  now  diluted  about 
five  times  with  distilled  water,  and  of  this  20  to  25  mils  (5.3 
to  6.7  f.S)  added  to  the  standard  solution,  which  is  then  made 
up  to  the  mark  with  water.  At  the  same  time  7  to  8  mils  (1.8 
to  2.1  fo)  of  the  freshly  diluted  Nessler's  solution  are  added 
to  the  unknown  solution  and  the  volume  made  up  to  25  mils 
(6.7  iZ)  in  the  graduate,  unless  a  high  content  of  urea  nitro- 
gen is  indicated,  in  which  case  more  Nessler's  solution,  up  to 
25  mils  (6.7  fo),  and  a  dilution  of  33}^,  50,  100  mils,  1.1,  1.6, 
3.3  f,3),  or  even  more,  may  be  needed  to  make  the  color  of 
the  unknown  of  approximately  the  same  intensity  as  the 
standard.  The  colorimeter  readings  should  be  made  without 
delay,  the  standard  prism  being  set  at  the  10  or  15  mm.  mark. 


*  The  solution  may  be  prepared  by  dissolving  0.944  Gm.  (14.5  grs.) 
ammonium  sulphate  or  0.764  Gm.  (11.7  grs.)  ammonium  chlorid  of  the 
highest  purity  in  distilled  water,  and  making  up  to  1000  mils  {33.3  fj) . 

t  For  the  modified  Nessler's  solution  place  100  Gms.  (3.2  f^)  mer- 
curic iodid  and  50  Gms.  (1.6  fj)  potassium  iodid,  both  finely  powdered, 
in  a  liter  (quart)  volumetric  flask  and  add  about  400  mils  (13.5  fS)  water. 
Now  dissolve  200  Gms.  (6.4  f5)  potassium  hydroxid  in  about  500  mils 
(16.6  fS)  water,  cool  thoroughly  and  add  with  constant  shaking  to  the 
mixture  in  the  flask ;  then  make  up  with  water  to  the  liter  mark.  This 
usually  becomes  perfectly  clear.  Keep  at  body  temperature  over  night,  or 
until  the  yellowish  white  precipitate,  which  may  settle  out,  is  thoroughly 
dissolved,  and  only  a  small  amount  of  dark,  brownish-red  precipitate  re- 
mains.   The  solution  is  now  ready  to  be  siphoned  off  and  used. 

39 


610  DISEASES    OF    THE    KIDXEYS. 

Creatinin.  About  10  mils  (2.7  fo)  of  blood  are  drawn 
directly  from  a  vein  into  a  small  bottle  containing  a  little 
powdered  potassium  oxalate  or  5  drops  (0.3  milj  of  a  20  per 
cent,  solution  to  prevent  clotting.  Six  mils  (1.6  fo)  of  the 
well-mixed  blood  are  treated  with  24  mils  (6.4  f5)  of  water 
(4  vol.).  After  the  corpuscles  have  been  laked,  about  1 
Gm.  (15.4  grs.)  of  dry  picric  acid  is  added  and  the  mixture 
stirred  at  intervals  with  a  glass  rod  until  it  is  light  yellow. 
When  the  protein  precipitation  is  complete,  the  mixture  is 
centrifuged  and  the  supernatant  fluid  filtered  through  a  small 
7  cm.  (2.7  in.)  filter  paper.  From  17  to  21  mils  (4.5  to  5.6  fo) 
of  filtrate  are  usualty  obtained.  To  10  mils  (2.7  fo)  of  the 
filtrate  is  added  0.5  mil  (8  w.)  of  10  per  cent,  sodium  hydrox- 
id,  and  a  similar  amount  of  alkali  added  to  10  mils  (2.7  fo) 
of  standard  creatinin  in  saturated  picric  acid  (containing  0.2, 
0.5  or  1.0  mg.  (0.003,  0.007  or  0.01  gr.)  creatinin  to  100  mils 
{Z.Z  f5)  of  picric  acid).  A  standard  solution  of  this  creatinin, 
1  mg.  to  1  mil  (0.01  gr.  to  16  w.)  is  kept  in  0.1  N  hydrochloric 
acid.  From  this  may  be  prepared  a  stock  solution  of  picric 
acid,  5  mgs.  to  100  mils  (0.07  gr.  to  3.3  f5)  by  diluting  5  mils 
to  100  mils  (1.3  to  Z.Z  i"^)  with  saturated  picric  acid.  By 
pipetting  0.4,  1.0  and  2.0  mils  (7,  16.2  and  32.4  m.)  of  this  solu- 
tion into  10  mils  (2.7  fo)  graduates  with  a  Mohr  pipette,  and 
diluting  to  the  mark,  standards  of  the  above  strength  are  pre- 
pared. For  the  Duboscq  'colorimeter  the  standard  prism  can 
be  set  conveniently  at  the  15  mm.  mark. 

The  estimation  of  the  creatinin  may  likewise  be  carried 
out  with  the  use  of  the  Autenrieth-Konigsberger  colorimeter 
of  Hellige.  In  this  case  less  blood  is  necessary.  Two  mils 
(32.4  «?.)  are  treated  in  a  cylindrical  centrifuge  tube  with  8 
mils  (2.1  fo)  of  water  and  other  manipulations  as  above.  For 
the  determination  proper,  0.1  mil  (2  m?)  of  10  per  cent,  sodium 
hydroxid  are  added  to  2  mils  (32.4  m.)  of  the  picric  acid 
filtrate  in  a  small  test-tube.  Simultaneousl}^  1  mil  (16  m.)  of 
the  alkali  is  added  to  20  mils  (5.3  fo)  of  a  saturated  solution 
of  picric  acid  containing  1.5  mgs.  (0.02  grs.)  creatinin  to  100 
mils  (3.3  f^)  to  ser^-e  as  standard  for  the  wedge.  At  the  end 
of  ten  minutes  the  wedge  is  filled  with  the  standard,  the  cup 
with  the  unknown,  and  readings  made.  The  following  for- 
mula, in  which  R  represents  the  colorimetric  reading  and  5 


CHRONIC   INTERSTITIAL   NEPHRITIS.  611 

the  dilution,  will  give  the  results  expressed  in  millij^rams  per 
100  mils  {3.3  £5)  blood. 

89  — R  X0.0179  X  5  =  mg.  creatinin  in  100  mils  (3.3  ff,,) 
blood. 

Creatinin  values  from  2.5  to  3.0  mgs.  (0.03  to  0.04  grs.)  per 
100  mils  {3.3  f§)  of  blood  should  be  viewed  with  suspicion, 
and  figures  from  3.0  to  5  mgs.  (0.04  to  0.07  grs.)  should  be 
regarded  as  decidedly  unfavorable,  while  an  amount  over  5 
mgs.  (0.07  grs.)  probably  indicates  an  early  fatal  termination. 

A  search  for  the  etiologic  factor  or  factors  in  each  case 
of  chronic  interstitial  nephritis  is  of  great  importance,  because 
the  removal  of  such  a  cause  is  essential,  if  one  hopes  to  check 
the  course  of  the  disease.  A  study  of  the  patient's  occupation, 
habits,  food,  etc.,  must  be  made  in  order  to  discover  and 
remove  anything  that  is  capable  of  increasing  the  normal 
work  of  the  kidneys,  or  that  may  act  as  a  renal  irritant.  Dis- 
orders of  digestion  and  metabolism,  sometimes  indicated  by 
indicanuria  and  oxaluria,  must  be  eliminated.  All  possible 
foci  of  infection,  such  as  the  teeth,  gums,  sinuses,  tonsils, 
prostate,  bladder,  and  so  forth,  must  be  investigated.  Those 
whose  occupation  exposes  them  to  the  danger  of  intoxication 
with  lead,  mercury,  and  poisonous  fumes  must  change  their 
work.  Any  fault  which  interferes  with  proper  digestion  must 
be  removed.  The  teeth  must  be  put  in  the  best  condition 
possible  to  insure  proper  mastication. 

Physical  overexertion  must  be  avoided  in  order  to  spare 
the  heart,  which  is  practically  always  hypertrophied  in  chronic 
interstitial  nephritis,  and  also  to  relieve  the  kidneys  of  the 
necessity  of  eliminating  the  resultant  surplus  of  waste  prod- 
ucts. Mental  overwork  is  as  injurious  as  physical  overexer- 
tion. Absolute  rest  in  bed  is  not  only  unnecessary,  but  injur- 
ious if  long  continued,  except  in  the  terminal  stages  of  the 
disease.  The  patient  should  be  permitted  to  be  about  doing-  a 
fraction  of  his  normal  amount  of  work.  Loss  of  sleep  and 
fatigue,  due  to  social  activities,  must  be  avoided.  In  short, 
the  patient  must  conserve  strength  and  energy,  and,  speaking 
generally,  his  activities  must  be  reduced  by  one-fourth  or  one- 
half.  Such  games  as  tennis,  baseball  and  swimming  must  be 
forbidden.      Moderate    walking   and    golf   in    moderation    are 


612  DISEASES    OF   THE   KIDNEYS. 

beneficial.    Nine  to  ten  hours  in  bed  each  night,  and,  in  addi- 
tion, in  certain  cases,  a  siesta  should  be  advised. 

Patients  with  chronic  interstitial  nephritis  do  best  in  a 
warm,  dry  climate,  because  in  such  a  climate  the  activity  of 
the  skin  lessens  the  work  required  of  the  kidneys.  In  order- 
ing a  patient  to  such  climate,  however,  one  must  take  under 
consideration  a  number  of  factors,  such  as  the  quality  of  the 
food  to  be  obtained,  the  altitude,  the  character  of  the  diver- 
sions offered,  the  season  of  the  year,  and  similar  details.  It 
is  also  to  be  remembered  that  the  patient  seldom  goes  alone 
to  the  place  selected,  but  takes  one  or  more  members  of  his 
family.  If  one  who  is  unable  to  find  his  own  diversion  and 
cannot  interest  himself  is  sent  to  a  place  where  there  are  few 
people  and  less  of  the  things  that  attract  and  interest  him, 
the  mental  unrest  and  unhappiness  would  nullify  any  advan- 
tage expected  to  be  derived  from  climate.  Likewise,  if  the 
creature  comforts  are  poor,  the  resultant  discomfort  may  pre- 
vent the  obtaining  of  sufficient  benefit  to  justify  the  expendi- 
ture of  the  time  and  money. 

A  climate  that  is  suitable  throughout  most  of  the  year  is 
found  in  southern  California  and  Hawaii.  The  winter  climate 
of  southern  Texas,  Arizona,  and  New  Mexico,  in  this  coun- 
try; Naples,  Algeria,  and  the  Island  of  Capri  abroad,  are 
suitable.  As  practically  every  case  of  chronic  interstitial 
nephritis  is  associated  with  cardiac  hypertrophy  and  hyper- 
tension, much  consideration  must  be  given  to  the  altitude  of 
the  resort  to  be  selected.  Many  patients  who  are  very  com- 
fortable at  elevations  up  to  800  or  1000  feet  become  dyspneic 
on  the  slightest  exertion  and  suft'er  from  cardiac  palpitation 
at  higher  altitudes.  Permitting  a  patient  with  considerable 
myocardial  change  to  go  to  a  high  altitude  may  result  in 
death.  It  is  plain  to  be  seen  that,  because  of  the  many  fac- 
tors which  must  be  considered,  no  one  place  can  be  selected 
to  suit  all  patients,  and  the  choice  is  made  largely  to  suit  the 
individual  requirements.  A  patient  may  be  very  much  better 
off  at  home  where  there  are  advantages  of  good  food  and 
comfortable  surroundings,  even  though  the  climate  is  severe, 
than  in  a  warm,  dry  climate,  with  poor  food,  away  from 
friends,  and  suffering  the  tortures  of  homesickness. 

Except   during   an   acute    exacerbation,    or   when   uremia 


CHRONIC    INTERSTITIAL    NEPHRITIS.  613 

occurs,  an  exclusive  milk  diet  should  not  be  prescribed,  for 
the  reason  that  the  food  value  is  too  small  as  compared  with 
the  bulk  of  liquid.  The  nephritic  patient  who  is  up  and 
around  requires  about  2000  calories.  To  supply  this  would 
require  5500  mils  (5^  qts.)  of  skimmed  milk  or  buttermilk, 
or  about  2750  mils  (2%'  qts.)  of  whole  milk.  The  transport- 
ing of  this  quantity  of  fluid  by  the  circulation  throws  addi- 
tional work  on  a  vascular  system  that  is  already  severely 
taxed.  It  is  better  to  supply  the  required  calories  by  a  mixed 
diet.  The  proteins  must  be  reduced,  usually  to  about  80  Gms. 
(2^  ozs.).  As  it  does  not  matter  in  what  form  of  food  the 
protein  is  supplied,  there  can  be  no  objection  to  the  taking 
of  a  small  quantity  of  meat.  The  quantity  of  protein-bearing 
food  is  the  important  thing,  and  this  quantity  may  be  roughly 
estimated  by  remembering  the  following  values :  The  aver- 
age helping,  3  tablespoonsful  (45  mils),  of  peas  and  beans  con- 
tains from  3  to  6  Gms.  (46.3  to  92.6  grs.)  of  proteins;  other 
vegetables  up  to  3  Gms.  (46.3  grs.).  A  slice  of  bread  Sy^ 
inches  (8.8  cm.)  square  and  5^  (1.2  cm.)  thick  contains  3  to 
4  Gms.  (46.3  to  61.7  grs.)  of  protein.  An  average  helping  (one 
slice)  of  the  meats  contains  20  to  30  Gms.  (308.6  to  462.9  grs.). 
Three  ounces  (93.3  Gms.)  of  fish,  which  is  an  average  helping, 
contain  10  to  20  Gms.  (154.3  to  308.6  grs.)  ;  one  egg  contains 
6  to  7  Gms.  (92.6  to  108  grs.).  The  protein  intake  must  be 
varied  according  to  the  nitrogen  content  of  the  blood,  as 
shown  by  the  blood  tests  for  uric  acid  and  urea.  An  increase 
in  their  retention  indicates  a  diminished  renal  efficiency,  and 
demands  decrease  in  the  protein  intake. 

Simple,  easily  digested  food  should  be  eaten  in  moderate 
amounts  and  with  regularity.  It  should  be  well  masticated. 
Rich  and  highly  seasoned  foods  should  be  avoided.  Common- 
sense  rules  concerning  the  restriction  or  avoidance  of  cakes, 
pies,  rich  puddings,  and  candies  must  be  obeyed.  Meat  occa- 
sionally should  be  permitted,  fish,  oysters  and  chicken  being 
preferable  to  the  red  meats.  The  feces  should  be  examined, 
and  if  it  is  shown  by  the  fermentation  test  that  the  proteins 
or  carbohydrates  are  not  being  properly  digested,  the  diet 
must  be  arranged  accordingly.  Frequent  urinatyses  should 
be  made  for  the  detection  of  indican  and  scatol,  which  indi- 
cate   absorption    of   putrefactive    materials    from    the    colon. 


614  DISEASES    OF   THE    KIDNEYS. 

When  present,  the  question  of  diet,  the  manner  of  mastica- 
tion, and  the  ability  of  the  digestive  juices  to  handle  the  food 
must  be  investigated. 

The  intake  of  fluid  should  be  restricted  in  a  measure. 
There  is  not  the  same  need  for  washing  out  the  tubules  in 
chronic  interstitial  nephritis  that  there  is  in  the  chronic  par- 
ench}'matous  type,  and,  besides,  the  heart  and  vessels  must 
not  be  overworked  by  the  necessity  of  carrying  large  amounts 
of  fluid.  In  the  average  case  the  quantity  of  fluid  should  be 
restricted  to  3  pints  (1420  mils)  a  day. 

Alcohol,  particularly  gin,  is  to  be  forbidden ;  or,  at  least, 
very  greatly  restricted.  In  some  instances  a  small  amount  of 
wine  ma^-  be  permitted  with  meals.  Tobacco,  because  of  its 
poisonous  action  upon  heart  and  vessels,  should  be  greatly 
restricted,  and,  when  possible,  quite  proscribed. 

The  skin  must  be  kept  in  good  condition,  because  of  its 
importance  as  an  organ  of  elimination.  A  warm  cleansing 
bath,  using  a  bland  soap,  such  as  pure  castile,  should  be  taken 
each  night  before  retiring.  Great  care  must  be  taken  to  avoid 
chilling  during  or  after  the  bath.  Cold  baths  are  contraindi- 
cated.  In  the  early  stages  of  the  disease,  during  warm 
weather,  a  cool  sponge  bath  will  be  refreshing,  and  will  do 
no  harm.  The  skin  must  always  be  protected  ag'ainst  sudden 
changes  of  temperature,  and  in  cool  and  cold  weather  woolen 
underwear  should  be  worn. 

Throughout  most  of  the  course  of  chronic  interstitial 
nephritis  the  heart  is  gradually  hypertrophying  to  carr}-  the 
gradually  increasing  burden  thrown  upon  it.  During  this 
process  no  direct  cardiac  treatment  is  indicated.  The  patient's 
mode  of  life  must  be  regulated  so  as  to  avoid  all  unnecessary 
circulator}'  strain.  In  many  cases  a  time  comes  when  the 
heart  can  no  longer  compensate,  and  dyspnea,  edema,  cyano- 
sis, and  other  signs  of  decompensation  become  evident.  Rest, 
both  physical  and  mental,  is  then  imperative.  Unless  dyspnea 
prevents,  the  patient  should  be  kept  in  bed,  w4iile  the  amount 
of  ing'ested  liquids  is  reduced  and  cardiac  stimulation  is  em- 
ployed. Digitalis,  in  doses  sufficient  to  produce  a  perceptible 
impression  on  the  heart,  should  be  given.  The  tincture  in 
doses  of  5  to  20  drops  (0.31  to  1.2  mil)  every  four  hours  or 
an  infusion  freshl}-  made  from  assayed  leaves  2  to  4  drams 


CHRONIC    INTI'RSTITIAI.    i\'l':J'l  I  KITIS.  615 

(7.5  to  15  mils)  every  three  or  four  hours  are  the  best  forms 
in  which  to  administer  the  drug.  Its  action  must  be  closely 
observed,  and  if  the  heart  becomes  arhythmic  or  irregular,  the 
use  of  the  drug  must  be  abandoned.  An  efficient  tincture  of 
strophanthus  is  often  of  great  value.  The  dose  for  each  in- 
dividual must  be  found  by  trial,  as  there  is  a  wide  difference 
in  patients  as  to  their  ability  to  take  the  drug.  In  some,  small 
doses  taken  for  a  few  days  produce  nausea,  vomiting  and 
diarrhea.  The  initial  dose  should  be  small,  3  drops  (0.15  mil) 
every  four  hours,  increased  as  rapidly  as  possible,  but  seldom 
exceeding  IQ  drops  (0.62  mil).  The  administration  of  tincture 
nux  vomica  in  15-  to  25-  drop  (0.93  to  1.56  mils)  doses  often 
yields  very  excellent  results.  To  tide  a  patient  over  a  cardiac 
■crisis,  strychnin  nitrate,  y^Q  to  %o  gfra^in  (0.002  to  0.003 
Gm.),  or  camphor,  1  to  3  grains  (0.06  to  0.19  Gm.),  in  10  to 
20  drops  (0.62  to  1.2  mils)  of  sterile  olive  oil,  may  be  given 
hypodermically.  Venesection  is  at  times  of  great  value  in 
extreme  hypertension  or  when  the  heart  is  dilated.  Ten  or 
more  ounces  (300  or  more  mils)  of  blood  should  be  abstracted, 
save  in  the  face  of  a  severe  anemia.  The  results  secured  must 
determine  the  question  of  its  repetition. 

The  systolic  blood-pressure  is  almost  always  considerably 
higher  than  in  health.  Rarely  it  may  be  as  high  as  320  mm. 
Unless  the  systolic  pressure  be  excessive,  i.c.^  over  200  mm., 
it  requires  no  treatment,  as  a  hypertension  of  this  sort  is 
largely  compensatory.  In  many  of  these  patients  unpleasant 
symptoms  are  experienced  when  the  blood-pressure  is  reduced 
to  150  mm.  or  lower.  AVhen  the  pressure  is  excessive  there 
is  danger  of  retinal  hemorrhage,  cerebral  hemorrhage,  and 
acute  dilatation  of  the  heart,  and  it,  therefore,  requires  treat- 
ment. 

The  use  of  drugs  to  lower  the  pressure  is  very  unsatisfac- 
tory, for  their  action  is  evanescent.  Nitroglycerin  is  very 
popular  in  the  treatment  of  hypertension,  but  in  the  doses 
given  ordinarily  it  is  incapable  of  doing  any  good.  When 
the  dose  is  sufficiently  large  to  make  an  impression  on  the 
vascular  hypertension  it  produces  headache  and  dizziness. 
Sometimes  by  the  use  of  this  drug  headache  is  produced 
without  any  observable  effect  on  the  hypertension.  Sodium 
nitrite,  1  to  5  grains  (0.06  to  0.32  Gms.),  is  sometimes  given. 


616  DISEASES    OF   THE   KIDNEYS. 

Like  nitroglycerin,  its  action  is  uncertain,  and  in  most  cases 
it  does  no  g"Ood,  and  often  causes  indigestion.  The  same  is 
true  of  sodium  or  potassium  iodid.  In  regard  to  the  iodids, 
it  is  to  be  remembered  that  some  patients  have  a  marked 
idiosyncrasy  toward  them.  Edema  of  the  fauces  and  uvula 
sometimes  occurs,  even  with  very  small  doses.  In  one  patient 
one  drop  of  the  saturated  solution  of  sodium  iodid  thrice 
daily  resulted  in  edema  of  the  uvula.  The  iodin  is  excreted 
by  the  kidneys;  therefore,  the  possibility  of  harming  these 
organs  must  be  kept  constantly  in  mind.  The  iodid  of 
sodium  is  to  be  preferred  to  the  iodid  of  potassium. 

The  most  efficient  and  safest  means  of  reducing  the  pres- 
sure is  by  elimination  through  the  skin.  For  this  purpose 
sweat-baths  are  used,  as  described  in  discussing  the  treatment 
of  acute  nephritis  (see  page  586).  The  use  of  diaphoretic 
drugs  is  to  be  avoided,  except  in  those  rare  cases  where  sweat- 
ing cannot  be  induced  by  the  various  hot  packs  and  baths. 

The  bowels  should  be  made  to  move  two  or  three  times 
daily  for  a  da}^  or  two  by  the  use  of  the  phosphate  or  sulphate 
of  sodium,  and  then  once  daily  for  several  days.  Brisk  purg- 
ing is  seldom  to  be  resorted  to  in  the  treatment  of  hyperten- 
sion. 

Dyspnea,  especially  of  the  nocturnal  type,  is  often  very 
distressing,  especially  when  associated  with  mental  excitabil- 
ity and  restlessness.  Opium,  ^  to  1  grain  (0.03  to  0.06 
Gm.)  in  a  suppository,  or  morphin,  ^  to  ^  grain  (0.008  to 
0.01  Gm.)  hypodermicall}^,  is  the  most  efficient  treatment, 
but  is  contraindicated  in  uremia.  AA'hen  the  dyspnea  and 
restlessness  are  not  very  marked,  sodium  or  potassium  bro- 
mid,  10  to  30  grains  (0.6  tO'  1.9  Gm.),  or  chloral,  5  to  10 
grains  (0.32  to  0.6  Gm.),  may  be  used,  but  are  very  likely 
to  cause  nausea,  and,  perhaps,  vomiting. 

Cerebral  hemorrhage,  even  though  slight,  demands  imme- 
diate and  absolute  rest  in  bed.  Absolute  rest  of  body  and 
mind  is  very  essential,  and  must  be  secured  with  opium  or 
morphin,  if  necessary.  If  the  patient  is  seen  at  the  beginning 
of  the  hemorrhage,  venesection  should  be  done  immediately, 
and  as  much  blood  as  safety  permits  should  be  withdrawn. 
If  hypertension  exists,  venesection  is  of  value,  even  some 
hours  after  the  occurrence  of  the  cerebral  hemorrhage.     Vis- 


CHRONIC   INTERSTITIAL   NEPHRITIS.  617 

itors  should  be  excluded  from  the  room,  and  all  noises 
reduced  to  a  minimum.  Purging  should  be  avoided  for  the 
first  forty-eight  hours,  because  of  the  importance  of  rest  as 
an  aid  to  the  cessation  of  bleeding.  Later  the  bowels  should 
be  kept  open.  The  food  should  be  small  in  quantity  and  con- 
centrated. The  intake  of  liquids  must  be  greatly  reduced. 
Stimulants  must  be  avoided.  After  sufficient  time,  usually 
several  days,  has  elapsed  to  insure  the  formation  of  a  firm 
clot  in  the  ruptured  vessel,  the  amount  of  liquid  consumed 
may  be  very  gradually  increased.  Subsequently,  general  mas- 
sage is  of  value.  When  the  ability  to  move  the  part  is 
regained,  daily  exercise  for  the  paretic  muscles  should  be 
advised  with  faradism. 

When  uremia  develops,  food  should  be  withheld,  and  later 
the  diet  should  be  limited  to  milk  or  skim  milk,  of  which 
6  ounces  (180  mils)  may  be  given  every  four  hours.  The 
patient  must  remain  in  bed,  and  active  elimination  through 
the  skin  and  bowels  begun.  Sweating  should  be  induced  by 
means  of  hot,  wet,  or  dry  packs,  hot-air  baths,  or  the  electric 
light  bath,  as  described  on  page  586.  These  should  be  given 
once,  and  in  urgent  cases,  even  twice  each  day.  Five  or  six 
watery  bowel  movements  should  be  secured  by  the  use  of 
phosphate  or  sulphate  of  sodium.  Venesection  may  be  very 
helpful.  Recently  one  of  the  authors  saw  a  young  adult 
woman  with  acute  parenchymatous  nephritis  following  preg- 
nancy, who  suddenly  became  uremic  with  white,  profusely 
sweating  skin,  moderately  dilated  pupils,  dark,  cyanotic  lips 
and  nails,  rapid  pulse,  and  sixty  respirations  per  minute,  with 
pulmonary  congestion  and  edema.  Death  seemed  imminent. 
The  prompt  removal  of  27  ounces  (810  mils)  of  blood  was 
followed  by  immediate  amelioration  of  symptoms  and  later 
by  recovery.  From  10  to  30  ounces  (300  to  900  mils)  of  blood 
should  be  withdrawn.  If  the  kidneys  are  capable  of  eliminat- 
ing water  this  should  be  freely  supplied  by  mouth,  if  the 
patient  is  conscious  and  the  stomach  is  retentive,  or  per  rec- 
tum, by  means  of  the  Murphy  drip  or  continuous  enteroclysis, 
as  described  on  page  583.  Lumbar  puncture  is  sometimes  of 
benefit  (v.  s.). 


618  DISEASES    OF    THE    KIDNEYS. 

AMYLOID  DEGENERATION  OF  THE  KIDNEYS. 

The  exact  nature  of  this  affection  is  still  unknown. 
Rokitansky,  in  1842,  first  described  the  rather  characteristic 
appearance  of  the  disease  in  the  kidneys  and  thought  the  con- 
dition one  of  lardaceous  or  fatty  infiltration.  Virchow  con- 
sidered the  substance  as  related  to  amyloid  and  cellulose,  and 
gave  it  the  name  of  amyloid,  which  is  still  in  use,  although 
it  is  definitely  known  that  the  substance  is  not  amyloid 
material.  The  manner  in  which  the  change  in  the  kidneys  is 
brought  about  is  not  known. 

It  seems  to  follow  in  the  wake  of  infections,  and  is  con- 
sidered a  secondary  disease.  The  degeneration  is  usually 
found  also  in  the  liver  and  the  spleen,  and  is  most  commonly 
encountered  in  pulmonary  tuberculosis,  especiall}-  when  char- 
acterized by  cavity  formation  and  an  abundant  purulent  ex- 
pectoration.    It  is  sometimes  seen  in  cases  of  bronchiectasis. 

In  protracted  suppuration  in  an}-  part  of  the  body,  but 
especially  of  bones  and  joints,  it  is  often  seen.  Syphilis, 
either  acquired  or  hereditary,  is  a  common  cause.  It  may 
occur  in  association  with  chronic  parenchymatous  or  chronic 
interstitial  nephritis. 

The  kidneys  are  usually  larger  than  normal,  unless  the 
degeneration  occurs  in  kidneys  that  have  been  contracted  by 
chronic  interstitial  nephritis.  They  are  pale  with  opaque, 
yellowish-white  mottlings,  and  the»capsule  strips  easily,  leav- 
ing a  smooth  surface.  On  section  the  tissue  is  gray  and 
translucent,  except  in  the  yellow,  opaque  areas,  where  fat 
globules  and  dead  cells  are  accumulated.  The  glomeruli  are 
visible  and  prominent  as  translucent  points.  The  amyloid 
deposit  acquires  a  reddish  brown  or  mahogany  color  on  the 
application  of  Lugol's  iodin  solution.  Microscopically,  the 
deposit  is  found  chiefly  about  the  blood-vessels  and  in  the 
glomeruli.  The  epithelial  cells  of  the  tubules  show  advanced 
degeneration. 

In  many  instances  the  symptoms  produced  by  the  primary 
disease,  i.e.,  tuberculosis,  syphilis,  suppurative  process,  com- 
pletely overshadow  the  symptoms  produced  by  the  degenera- 
tion in  the  kidneys.  As  a  rule,  the  urine  is  abundant  in  quan- 
tity, clear,  pale  yellow  in  color,  acid,  and  has  a  low  specific 


NEPHROLITHIASIS.  619 

gravity.  The  albumin  percentage  is  high,  and  there  is  very- 
little  sediment,  which  contains  only  a  few  hyalin,  fatty  and 
sometimes  waxy  casts,  an  occasional  leucocyte,  and  very  few 
epithelial  cells. 

Dropsy  is  a  frequent  accompaniment  of  amyloid  disease. 
Probably  the  greatest  factor  in  the  production  of  edema  is 
the  cachexia  of  the  primary  disease.  Diarrhea  is  not  infre- 
quent, and  may  be  due  to  renal  insufficiency  (uremia),  or  to 
amyloid  disease  of  the  intestinal  mucous  m'embrane. 

The  therapeutic  measures  to  be  adopted  relate  to  the 
active  treatment  of  the  primary  disease,  rather  than  to  the 
amyloid  lesion  per  se.  In  suppurative  conditions,  such  as 
empyema  or  abscesses  in  any  part  of  the  body,  the  pus  must 
be  given  a  free  outlet,  and  every  method  known  to  modern 
surgery  employed  in  securing  prompt  healing.  If  the  primary 
disease  is  tuberculosis  or  syphilis^  active  treatment  of  this 
may  prevent  the  occurrence  of  amyloid  degeneration. 

General  hygienic  measures,  such  as  the  care  of  the  skin, 
the  securing  of  fresh  air  and  plenty  of  sleep,  are,  of  course, 
essential.  Food  should  be  given  in  accordance  with  the  diges- 
tive powers  of  the  patient.  The  object  should  be  to  secure 
the  maximum  nourishment  possible. 

NEPHROLITHIASIS. 

By  this  term  is  meant  the  precipitation  in  the  kidney  sub- 
stance or  in  the  renal  pelvis  of  urinary  solids,  forming-  con- 
cretions that  vary  in  sife  from  sand  g*rains  to  large  concre- 
tions or  calculi.  Most  commonly  they  are  formed  of  uric  acid, 
with  some  sodium  and  ammonium  urate  and  a  small  quan- 
tity of  xanthin.  The  uric  acid  stones  are  usually  yellowish, 
reddish  brown  or  brick-red  in  color,  rather  smooth,  most 
often  rounded  and  hard.  The  uric  acid  nature  of  the  calculus 
may  be  discovered  by  treating  some  of  the  powdered  stone 
with  nitric  acid  in  a  porcelain  dish  and  evaporating  to  dry- 
ness. After  cooling  allow  a  drop  or  two  of  ammonia  water 
to  come  in  contact  with  the  residue.  Uric  acid  or  urates  will 
give  a  light  blue  or  violet  color. 

Next  in  the  order  of  frequency  are  the  stones  composed 
of  calcium  oxalate.    They  are  generally  of  a  dark  gray,  almost 


620  DISEASES    OF   THE   KIDNEYS. 

blackish  color.  They  are  extremely  hard  and  may  occur  as 
small,  smooth  concretions,  or  as  medium-sized  or  large  stones 
with  a  very  rough  surface,  generally  called  a  mulberry  cal- 
culus. The  roughened  surface  is  due  to  the  protrusion  of  the 
sharp-pointed  octahedral  crystals  of  calcium  oxalate,  which 
crystals  lacerate  the  tissue  and  produce  early  and  severe 
symptoms.  When  some  of  the  powdered  stone  is  gently 
heated,  then  treated  with  h3^drochloric  acid,  it  effervesces. 

Phosphatic  calculi,  which  consist  in  the  main  of  calcium 
phosphate  and  ammonium-magnesium  phosphate,  are  uncom- 
mon in  the  kidneys.  The  formation  presupposes  ammoniacal 
decomposition  of  the  urine,  which  is  rare  in  the  kidneys,  but 
common  in  the  bladder,  and  is  usually  due  to  infection  with 
various  micro-organisms.  These  stones,  Avhen  found  in  the 
kidney,  are  usually  in  association  with  the  presence  of  pus. 
If  pyogenic  infection  of  the  kidneys  takes  place  after  a  uric 
acid  or  an  oxalate  stone  has  formed  therein,  these  calculi  will 
be  coated  with  a  layer  of  phosphates.  The  surface  of  phos- 
phatic calculi  is  generally  rough,  but  occasionally  it  may  be 
rather,  smooth.  They  may  be  white  or  gray  or  tinted  yellow. 
The  stone,  when  powdered,  dissolves  in  acetic  or  hydrochloric 
acid. 

The  cause  of  the  formation  of  renal  calculus  is  not  clear. 
That  the  appearance  of  the  urates,  uric  acid,  oxalates,  etc.,  in 
the  kidneys  in  large  amount  is  due  to  disorders  of  metabolism 
is  undoubted.  Osier  states  that  sedentarj^  occupations  seem 
to  predispose  to  stone.  The  influence  of  diet  is  not  definitely 
known,  but  it  is  probable  that  when  purin  bodies  in  large 
quantity  are  ingested,  and  because  of  insufficient  exercise  or 
other  cause  are  improperly  oxidized,  uric  acid  or  urate  stones 
may  develop.  The  same  is  true  of  the  ingestion  of  foods  rich 
in  oxalic  acid.  Nephrolithiasis  may  occur  at  an}-  age,  but  it 
is  most  commonly  encountered  in  the  fourth  decade  of  life. 
Holt  states  that  uric  acid  deposits  in  the  kidneys  of  children 
are  Ytry  common.  Males  are  more  frequently  afifected  than 
females. 

The  kidney  may  remain  quite  healthy,  even  in  the  pres- 
ence of  a  calculus,  but  generally  a  diffuse  nephritis  is  present. 
If  the  ureter  is  obstructed,  hydronephrosis  develops;  and,  if 
an  infection  occurs,  a  pyonephrosis  results,  in  which   event 


NEPHROLITHIASIS.  621 

the  renal  destruction  may  be  so  great  that  the  kidney  is  con- 
verted into  a  large,  irregular,  fluctuating  mass  with  thick 
walls.  The  number  of  stones  varies  from  one  to  many.  They 
are  usually  found  in  the  pelvis  or  calices ;  less  commonly 
they  are  imbedded  in  the  substance  of  the  kidney.  It  is  not 
uncommon  for  renal  litliiasis  to  be  bilateral. 

A  stone  or  stones  may  remain  in  the  kidney  for  years 
without  producing  any  symptoms  until  the  existence  of  a 
pyog'enic  infection  is  betrayed  by  chills,  fever  and  sweats 
with  pyuria.  In  most  instances,  however,  a  dull  aching  pain, 
sometimes  scarcely  more  than  a  discomfort,  in  the  lumbar 
region  is  noted.  At  times  the  pain  becomes  colicky  in  char- 
acter and  radiates  downward  and  forward  to  the  groin,  and 
often  into  the  testicle.  Sometimes  it  is  referred  to  the  head 
of  the  penis.  The  pain  may  occur  very  suddenly,  and  be  so 
extremely  severe  that  beads  of  sweat  appear  on  the  forehead. 
During  the  paroxysm  the  patient  may  be  unable  to  move,  but 
usually  he  tosses  wildly  about,  and  rolls  on  the  floor  shriek- 
ing and  groaning.  Pain  of  this  character  is  spoken  of  as 
renal  colic,  and  is  often  accompanied  by  nausea  and  vomit- 
ing. The  intense  pain  lasts  for  several  hours,  as  a  rule,  unless 
treatment  is  instituted,  and  passes  away  rather  abruptly, 
sometimes  suddenly.  It  is  often  followed  by  soreness,  and 
at  times  by  prostration.  After  the  attack  the  first  urine 
voided  may  contain  macroscopic  blood.  Nearly  always  mi- 
croscopic blood  will  be  found.  Occasionally  anuria  occurs 
and  may  become  a  very  serious  symptom.  The  mortality 
rate  of  calculus  anuria  is  very  high. 

W.  F.  Braasch  and  A.  B.  Moored  state  that  of  the  742 
cases  of  lithiasis  of  renal  origin  operated  on  at  the  Mayo 
Clinic  up  to  June,  1915,  512  stones  were  removed  from  the 
kidney,  and  230  were  found  lodged  in  some  portion  of  the 
ureter.  In  ureteral  stone,  the  pain,  which  is  due  either  to 
intrarenal  tension  as  a  result  of  urinary  obstruction,  or 
because  of  localized  infectious  changes,  was  referred  largely 
to  the  renal  region  in  67  per  cent,  of  the  cases ;  to  the  upper 
abdominal  quadrant  in  15  per  cent.;  to  the  region  of  the 
lower  ureter  in  9  per  cent. 

Renal  colic  is  not  diagnostic  of  stone,  as  it  may  occur  in 
renal  hemorrhage  due  to  the  passage  of  clots,  or  as  a  result 


622  DISEASES    OF   THE    KIDNEYS. 

of  obstruction  of  the  ureter  from  other  causes.  An  ,r-ray 
examination  is  of  great  aid  in  the  diagnosis. 

Calculi  containing  calcium  throw  a  shadow,  but  50  per 
cent,  of  stones  are  not  revealed  by  Rontgen-rays  for  vari- 
ous reasons,  such  as  obesity,  embedding  of  a  stone  in  fat,  soft 
structure  of  a  stone,  or  its  obstruction  by  the  iliac  artery. 
Conversely,  all  shadows  shown  in  the  region  of  the  kidney 
by  the  ,^'-rays  are  not  due  to  stones,  but  may  have  been  caused 
by  glands,  'calcareous  deposits,  or  phleboliths. 

In  all  cases  where  the  jr-ray  evidence  is  doubtful  the 
ureteral  catheter  must  be  used.  W.  F.  Braasch^^  states  that 
80  per  cent,  of  ureteral  stones  were  detected  by  the  catheter, 
and  70  per  cent,  of  stones  in  renal  pelvis  were  thus  detected. 

The  frequent  or  continuous  presence  of  urates,  uric  acid 
and  oxalates  in  the  urinary  sediment  between  the  attacks  of 
colic,  or  associated  with  dull  aching  in  the  lumbar  region,  is 
rather  good  circumstantial  evidence  in  favor  of  the  diagnosis 
of  renal  calculus.  Many  years  ago  one  of  the  authors  saw  a 
man  of  gouty  diathesis,  aged  60  years  or  more,  who  presented 
no  definite  symptoms  of  renal  disease  excepting  polyuria 
leading  to  the  suspicion  of  contracted  kidney.  He  died  sud- 
denly of  uremia.  Each  kidney  was  transformed  into  a  large 
bag  containing  enormous  stones  which,  weighing  about  half 
a  pound  (0.2  Kg.),  occupied  the  pelvis  and  calices.  The  sub- 
stance of  the  kidney  was  reduced  to  a  mere  rim  yi  of  an  inch 
(6.3  mm.)  in  thickness.  These  stones  had  existed  for  years, 
and  produced  absolutely  no  symptoms. 

As  a  rule  the  physician  is  first  called  in  to  treat  the  renal 
colic.  If  the  attack  is  mild  a  hot  bath  will  relax  the  spasm 
and  end  the  attack.  The  patient  should  be  placed  in  a  tub 
of  water  of  sufficient  depth  to  cover  the  legs  and  trunk.  The 
temperature  of  the  water  should  be  100°  F.  {2)7.7°  C),  which, 
after  the  patient  has  been  in  the  tub  a  minute  or  two,  should 
be  raised,  in  the  course  of  ten  to  fifteen  minutes,  to  110°  or 
115°  F.  (43.3°  or  46.1°  C),  depending  upon  the  ability  of  the 
patient  to  endure  heat.  While  in  the  bath  an  ice-bag  or  cloth 
wrung  out  of  very  cold  water  should  be  placed  on  the  head. 
The  bath  should  be  discontinued  if  faintness  occurs.  After  the 
bath  the  patient  is  quickly  but  gently  dried  and  placed  in  bed 
between  blankets.    It  is  important  that  during  this  treatment 


NEPHROLITHIASIS.  623 

the  patient  be  as  passive  as  possible.  He  should  not  dry  him- 
self, and  all  his  movements  should  be  slow  and  gentle.  A 
hot-water  bottle  should  be  applied  to  the  site  of  pain  after 
the  patient  is  in  bed,  or,  still  better,  hot  fomentations  should 
be  used.  These  consist  in  the  application  of  towels  wrung 
out  of  boiling  water,  and  applied  to  the  site  of  pain.  Care 
must  be  taken  to  wring  them  quite  dry  to  avoid  scalding  the 
skin.  The  towels  must  be  removed  as  often  as  necessary 
(usually  every  three  to  five  minutes)  to  maintain  the  heat. 
Poultices  are  distinctly  inferior,  as  they  are  not  only  slowly 
made,  but  quickly  lose  their  heat,  after  which  they  add  to  the 
discomfort  of  the  patient.  The  materials  that  enter  into  the 
composition  of  the  poultices  are  valueless  in  the  treatment  of 
colic,  the  sole  value  of  the  poultice  residing  in  the  heat. 

If  the  pain  continues  to  increase,  or  if  the  attack  is  severe 
from  the  onset,  a  hypodermic  injection  of  morphin,  54  grain 
(0.01  Gm.),  and  atropin,  %oo  grain  (0.0006  Gm.),  must  be 
administered.  It  is  best  to  begin  with  ^  of  a  grain  (0.01  Gm.) 
and  repeat  in  fifteen  or  twenty  minutes  if  ineffectual.  These 
patients  tolerate  large  doses  of  morphin,  and  the  drug 
must,  therefore,  be  used  for  effect,  without  regard  to  dose. 
Atropin,  because  of  its  ability  to  inhibit  contraction  of 
unstriated  muscle,  is  of  distinct  value.  It  should  be  given 
in  doses  of  %5o  of  a  grain  (0.0004  Gm.),  and  repeated  as 
often  as  necessary,  watching  closely,  however,  to  avoid  toxic 
effects. 

The  use  of  chloroform  to  quiet  the  patient  is  not  advis- 
able,, because  of  the  possibility  of  the  danger  of  disturbing 
the  action  of  an  already  functionally  deranged  kidney.  The 
likelihood  of  its  favoring  the  occurrence  of  anuria,  so  fatal 
in  renal  lithiasis,  also  is  to  be  recalled. 

If  collapse  occurs,  aromatic  spirits  of  ammonia  should  be 
given  by  mouth  or  by  inhalation,  and,  if  necessary,  camphor, 
5  grains  (0.3  Gm.)  in  oil,  or  strophanthin  (Merck's),  %2o  to  ^^o 
grain  (0.0005  to  0.0011  Gm.)  should  be  given  intravenously. 

Should  no  urine  be  voided  within  a  few  hours  of  the 
attack,  examination  should  be  made  to  determine  whether 
this  is  due  to  retention  or  suppression.  If  due  to  suppres- 
sion, draughts  of  hot  lemonade  should  be  given  and  more 
heat  applied  to  the  lumbar  regions.     Anuria  lasting  more  than 


624  DISEASES    OF   THE    KIDNEYS. 

twenty-four  hours  is  serious,  and  surgical  intervention  be- 
comes necessar}^ 

The  mortahty  rate  is  much  lower  in  those  cases  that  are 
promptly  operated  upon.  Continuous  enteroclysis  of  normal 
salt  solution  or  2  per  cent,  dextrose  solution  is  indicated. 
Ten  g-rains  (0.6  Gm.)  of  theobromin-sodium-salicylate  (di'u- 
retin)  every  four  hours  is  often  of  value. 

After  the  attack  of  renal  colic,  the  case  must  be  carefully 
studied,  with  the  object  of  determining  the  functional  capac- 
ity of  each  kidney  by  the  phenolsulphonephthalein  test.  This 
necessitates  differential  catheterization,  and  no  operative 
treatment  must  be  considered  until  after  this  information  is 
at  hand.  The  urine  must  be  repeatedly  examined,  and  if  uric 
acid,  urates,  or  oxalates  are  found,  the  diet  must  be  arranged 
so  as  to  diminish  the  intake  of  the  bodies  that  form  these 
compounds.  Water  must  be  administered  to  flush  the  kid- 
neys freely.  To  prevent,  so  far  as  possible,  the  occurrence 
of  infection,  ihexamethylene-tetramin  (urotropin),  5  to  10 
grains  (0.32  to  0.65  Gm.),  two  or  three  times  daily  should 
be  given.  It  must  be  remembered  that  hematuria  may  follow 
the  too  prolonged  administration  or  the  giving  of  too  large 
doses  of  this  drug. 

If  the  patient  has  had  but  one  attack  of  colic  and  can  be 
kept  under  close  observation  so  as  to  be  assured  that  infec- 
tion is  not  taking  place,  operation  may  be  indefinitely  post- 
poned and  often  avoided.  If  pus  begins  to  appear  in  the  urine 
and  differential  catheterization  shows  that  it  comes  from  a 
single  kidney,  operation  is  indicated,  provided  the  phenolsul- 
phonephthalein test  shows  these  organs  to  be  functionating 
sufficiently.  If  a  calculus  be  passed,  symptoms  disappear, 
and  an  .i--ray  examination  shows  no  shadows,  the  operation 
should  be  postponed  until  symptoms  arise  to  indicate  defi- 
nitely the  presence  of  another  stone.  If  an  ,r-ray  examina- 
tion reveals  several  shadows  in  the  kidney  or  ureter,  opera- 
tion is  advisable. 

Before  an  abdominal  operation  is  attempted,  the  passage 
of  the  stone  in  the  ureter  may  be  aided  by  (1)  catheter 
manipulation;  (2)  injection  of  sterile  glycerin  or  oil;  (3) 
fulguration;  (4)  ureteral  dilatation;  (5)  cutting  of  the  meatus, 
and  (6)  the  use  of  ureteral  forceps. 


HYDRONEPHROSIS.  625 

It  has  been  claimed  that  the  injection  of  oil  and  glycerin 
into  the  ureter  would  both  increase  the  peristalsis  and  lubri- 
cate the  walls  of  the  ureter  so  that  the  stone  would  slip  out, 
but  this  theory,  however,  is  not  corroborated  by  clinical 
observation.  It  is  difficult  to  conceive  how  the  natural  efforts 
of  peristalsis  or  how  the  natural  lubrication  in  the  ureteral 
mucosa  could  be  improved  on.^^ 

HYDRONEPHROSIS. 

By  hydronephrosis  is  meant  the  overdistension  of  the 
renal  pelvis  with  urine.  The  disease  is  usually  confined  to 
one  kidney,  and  is  due  to  obstruction  somewhere  along  the 
course  of  the  ureter.  Bilateral  hydronephrosis  is  very  rare. 
It  may  occur  as  the  result  of  a  new  growth  compressing  both 
ureters  or  occluding  both  ureteral  orifices  in  the  bladder. 
Hydronephrosis  may  be  either  congenital  or  acquired.  The 
etiological   conditions   responsible   for  the   acquired   type   are 

(1)  stricture  following  inflammatory  and  traumatic  lesions; 

(2)  blockage  of  a  ureter  by  a  calculus;  (3)  compression  of 
the  ureter  by  a  tumor;  (4)  constriction  of  the  ureter  by 
fibrous  bands,  due  to  an  inflammatory  process  in  neighbor- 
ing tissues.  W.  F.  Braaschi*  states  that  the  etiological  con- 
ditions commonly  observed  in  congenital  cases  are  (1)  anom- 
alous renal  blood-vessels ;  (2)  atresia  of  the  ureter  near  the 
renopelvic  juncture,,  and  (3)  displaced  kidne3'S.  Of  27  cases 
studied  at  the  Mayo  Clinic,  20  w^ere  associated  with  an 
anomalous  blood-vessel.  Usually  such  a  blood-vessel  is  given 
off  from  the  aorta  or  renal  artery,  and,  passing  the  ureter 
anteriorly,  enters  the  kidney  near  the  lower  pole. 

The  presence  alone  of  an  anomalous  vessel  is  insufficient 
to  cause  hydronephrosis,  as  the  ureter  and  the  anomalous 
vessel  are  not  usually  in  contact.  It  is  probable  that  the  loss 
of  perirenal  fat  permits  enough  sagging  of  the  kidney  to 
cause  the  ureter  to  bend  over  the  vessel  to  form  a  kink.  The 
chief  symptom  is  pain  in  the  upper  lateral  aspect  of  the 
abdomen.  The  pain  is  not  referred,  as  in  renal  or  ureteral 
calculus,  but  remains  localized,  and  though  severe,  it  is  less 
so  than  the  pain  due  to  renal  stone.  It  is  usualh^  acute  for 
hours,  and  followed  by  a  soreness  that  may  persist  for  sev- 


626  DISEASES    OF    THE    KIDNEYS. 

eral  days.  Quite  commonh'  nausea  and  vomiting  accompany 
the  pain.  If  the  hydronephrosis  be  sufficiently  large,  a  tumor 
may  be  palpable,  which  may  suddenly  disappear,  due  to  the 
escape  of  urine  through  the  ureter,  A  radiogram  made  after 
the  injection  of  argyrol  and  bismuth  solutions  into  the  renal 
pelvis  is  of  great  aid  in  the  diagnosis,  and  is  especially  valu- 
able in  distinguishing  between  lithiasis  and  nephrosis.  A 
histor}^  of  polyuria  following  the  attack  of  pain  is  always 
suggestive. 

Cystoscopic  examination  and  catheterization  of  the  ureters 
is  of  great  assistance  in  the  diagnosis.  The  capacit}-  of  the 
renal  pelvis  rndLy  be  measured  by  injecting  boric  acid  solution 
stained  with  methylene  blue,  the  dye  being  used  to  determine 
whether  there  is  an}-  return  flow  alongside  the  catheter.  The 
normal  capacity  of  the  renal  pelvis  is  5  to  15  mils  (1.3  to  4 
fo).  Sometimes  as  much  as  30  mils  (1  oz.)  may  be  injected 
before  pain  is  caused.  If  40  mils  (1.3  oz.)  or  more  can  be 
tolerated  without  pain,  a  diagnosis  of  dilatation  of  the  pelvis 
is  justified. 

AVhen  pain  is  severe,  morphin,  }^  to  ^  grain  (0.008  to 
0.01  Gm.),  may  be  necessary,  and  hot  applications  are  often 
soothing.  As  a  rule,  it  is  necessar}-  to  relieve  the  obstruction 
of  the  ureter  b}^  surgical  measures.  In  those  cases  due  to 
kinking  of  the  ureter,  the  kidney-  should  be  anchored  in  its 
normal  position.  When  the  renal  substance  is  almost  en- 
tirely destroyed,  and  when  infection  has  taken  place,  the 
entire  kidney  should  be  removed. 

PYOGENIC  INFECTIONS  OF  THE  KIDNEYS. 

Under  this  heading  are  considered  pyelitis,  pyelonephritis, 
suppurative  pj-elonephritis,  suppurative  nephritis,  and  pyo- 
nephritis. 

B3^  pyelitis  is  meant  an  inflammation  of  the  renal  pelvis; 
if  the  substance  of  the  kidnc}'  is  also  involved,  the  term 
pyelonephritis  is  used.  If  miliarv  abscesses  are  scattered 
throughout  the  kidnej-  substance  and  in  the  pelvis,  the  con- 
dition is  spoken  of  as  suppurative  pvelonephritis ;  and  if  the 
abscesses  are  limited  to  the  renal  substance,  it  is  termed  sup- 
purative nephritis.     If  the  suppurative  inflammation  results 


PYOGENIC    INFECTION.  627 

in  the  formation  of  one  or  more  fairly  large  circumscriljed 
collections  of  pus  in  the  renal  substance,  it  is  caflcd  abscess 
of  the  kidney.  When,  from  ureteral  obstruction  to  the  escape 
of  urine  from  the  pelvis  of  the  kidney,  distension  occurs  with 
subsequent  infection,  the  change  in  the  organ  is  called 
pyonephrosis. 

Many  varieties  of  micro-organism  are  capable  of  produc- 
ing- these  pyogenic  inflammations,  but  the  bacteria  most  com- 
monl)^  found  are  the  colon  l^acillus,  the  staphylococcus,  and 
the  streptococcus.  The  incidence  of  the  colon  bacillus  is 
more  frequent  than  that  of  the  other  two  micro-organisms. 
The  bacteria  may  reach  the  kidneys  through  the  blood — 
hematogenous  infection — from  a  focus  elsewhere  in  the  body, 
as  infected  tonsils,  abscesses  about  the  teeth  or  elsewhere, 
and  as  a  result  of  pyemia,  septicemia  and  ulcerative  endo- 
carditis. As  a  result  of  fecal  stasis  in  the  colon,  the  colon 
bacilli  may  find  their  way  into  the  intestinal  wall  and  be  con- 
veyed to  the  kidneys  by  the  blood.  The  infection  may  be 
urogenic,  i.e.,  arising  from  an  ascending  infection  from  the 
bladder  or  ureter.  This  is  observed  in  cystitis,  especially  in 
individuals  with  low  resistance  and  relaxed  musculature. 
Obstruction  of  the  ureter  by  a  twist  or  by  a  calculus,  or  as 
the  result  of  compression  by  a  neoplasm,  followed  by  infec- 
tion converts  a  hydronephrosis  into  a  pyonephrosis.  Pyo- 
genic infection  of  organs  or  tissues  in  the  vicinity  may 
extend  to  the  kidney,  and,  rarely,  renal  infection  is  the  result 
of  a  penetrating  wound. 

When  thci  renal  pelvis  alone  is  afifected  the  pathologic 
picture  is  variable,  depending  upon  the  length  of  time  the 
infection  has  persisted,  and  the  virulence  of  the  infecting 
organism.  As  a  rule,  staphylococcus  infections  are  relatively 
mild,  while  infections  with  the  streptococcus  may  be  very 
severe.  In  acute  pyelitis  there  is  marked  congestion  and 
swelling  of  the  mucous  membrane,  with  pus  cells,  and,  some- 
times, red-blood  cells  upon  its  surface. 

In  some  of  the  severe  types  of  streptococcus  infections, 
punctiform  hemorrhages  are  observed.  In  chronic  inflamma- 
tion the  mucous  membrane  is  much  thickened,  brownish  or 
grayish  in  color,  and  ulcerations  are  commonly  present. 
When  the  infection  occurs  after  obstruction  of  a  ureter,  the 


628  DISEASES    OF   THE    KIDNEYS. 

wall  of  the  pelvis  may  be  thinned  from  overdistension,  and 
a  deposit  of  urinary  crystals,  usually  phosphates,  takes  place. 
The  contained  urine  is  usually  turbid  and  foul-smelling. 

Extension  to  the  renal  substance  is  indicated  by  grayish 
lines  radiating  upward  from  the  papillae,  which  lines,  under 
the  microscope,  are  found  to  be  composed  of  pus  cells  and 
bacteria.  The  microscope  may  likewise  reveal  areas  of  round 
cell  infiltration.  Miliary  abscesses  may  be  seen  scattered 
through  the  cortex  and  medulla.  In  some  instances,  by 
fusion  of  the  miliary  abscesses,  larger  ones  are  formed.  Un- 
less the  infection  be  hematogenous,  usually  but  one  kidney  is 
infected,  the  unaffected  organ  becoming  hypertrophied  in 
chronic  cases,  to  compensate  for  the  gradually  disappearing 
function  of  its  diseased  mate.  One  of  the  authors  has  ob- 
served in  a  patient,  dead  of  t}^phoid  fever,  an  impacted  stone 
in  the  left  ureter  near  the  bladder  wall,  causing  complete 
obstruction,  which  had  evidently  existed  for  years.  The  kid- 
ney was  shrunken  and  the  pelvis  and  calices  slightly  dilated. 
The  right  kidney  was  about  twice  the  normal  in  size  and 
structure,  and  no  symptoms  of  renal  inadequacy  or  disease 
were  present. 

Pyogenic  infections  of  the  kidney  may  exist  with  no 
symptoms,  or  the  symptoms  may  be  slight  and  completely 
overshadowed  by  those  of  the  primary  infection,  such  as 
cystitis  or  septic  endocarditis.  The  principal  subjecti^'^ 
signs  are  pain,  swelling,  and  constitutional  disturbances  with 
urinary  abnormalities.  The  changes  in  the  urine  are  most 
important.  Pus  cells  are  practically  always  found,  but  may 
be  so  few  as  to  be  detected  onl)?-  by  microscopic  examination 
of  the  urine,  or  may  be  sufficient  in  number  to  be  seen  by 
the  naked  eye  as  pus.  Sometimes  they  are  absent.  In  severe 
acute  and  chronic  cases  blood  may  appear.  Bacteria  are  often 
found  in  abundance.  Albumin  is  present,  usually  in  amounts 
larger  than  can  be  accounted  for  by  the  presence  of  pus. 
Casts  may  be  present,  but  unless  a  nephritis  coexists  they 
are  likely  to  be  few  or  absent.  Leucocytic  or  pus  casts  may 
be  found.  The  reaction  of  the  urine  depends  upon  the  invad- 
ing- type  of  micro-organism.  In  colon  bacillus  infections  the 
urine  is  usually  acid.  Staphylococcus  infections  are  likely  to 
produce  an  alkaline  urine,  in  which  event  the  odor  will  be 


PYOGENIC  INFECTION.  629 

ammoniacal,  and  the  sediment  will  contain  a  large  number 
of  amorphous  and  triple  phosphates. 

Pain,  when  present,  is  usually  not  severe,  and  is  com- 
plained of  by  the  patient  as  a  dull  ache  in  the  lumbar  region. 
Deep  pressure  over  the  affected  kidney  may  reveal  tender- 
ness. Sometimes  acute  exacerbations  of  pain  occur,  and 
attacks  of  colic  may  be  produced  by  the  passage  of  clots  of 
blood,  or  of  plugs  of  tough  mucopus. 

In  pyonephrosis  a  tumor  mass  may  be  felt,  which  is 
usually  tender  on  pressure.  In  most  other  pyogenic  infec- 
tions of  the  kidney  the  organ  is  not  palpable. 

The  classic  constitutional  symptoms  of  the  presence  of 
pus  (chills,  fever  and  sweats)  may  be  present.  Sometimes 
only  occasional  slight  chilliness  is  noted  at  irregular  inter- 
vals, and  the  temperature  may  never  exceed  99°  F.  (37.2°  C). 
Sweats  may  occur  without  the  association  of  chills  and  fever. 
On  the  other  hand,  intermittent  fever  with  a  range  of  70°  F. 
(21.1°  C.)  may  occur,  with  rigor  and  sweats.  As  a  rule 
there  is  a  loss  of  appetite  and  a  feeling  of  malaise.  Usually 
a  positive  diagnosis  cannot  be  made  without  a  cystoscopic 
examination  and  ureteral  catheterization. 

If  the  etiology  of  pyogenic  infections  of  the  kidney  is 
borne  in  mind,  much  may  be  accomplished  in  prophylaxis  by 
removal  of  the  original  focus  of  infection.  Therefore,  infected 
tonsils,  abscesses  about  the  roots  of  teeth,  chronic  sinus  infec- 
tions, and  other  potential  causal  factors  of  sepsis  must  be 
removed ;  and  important  in  this  connection  is  the  fact  that 
collections  of  pus  deep  in  the  body  of  the  tonsil  or  abscesses 
at  the  apices  of  the  teeth  usually  do  not  drain  towards  the 
surface,  and  therefore  the  absorption  of  the  infectious  organ- 
ism is  enhanced.  It  is  also  to  be  remembered  that  commonly 
these  orginal  foci  of  infection  give  rise  to  no  symptoms,  or 
to  such  minor  symptoms  as  to  escape  the  patient's  attention. 
The  absence  of  symptoms  does  not  guarantee  that  such  a 
focus  will  not  produce  far-reaching  evil  effects  in  the  body. 

Fecal  stasis,  often  causing  chronic  or  recurrent  headaches 
and  other  symptoms  of  intestinal  toxemia,  favors  the  infection 
with  the  colon  bacillus,  and,  therefore,  a  torpid  bowel  is  to 
be  energetically  treated,  not  only  with  the  view  to  relieving 
the  immediate  expression  of  the  toxemia,  but  also  to  prevent 


630  DISEASES    OF    THE    KIDNEYS. 

the  occurrence  of  renal  infection  from  this  source.  Super- 
ficial ulceration  of  the  colonic  mucous  membrane,  not  uncom- 
mon in  constipation,  favors  the  entrance  of  colon  bacilli  into 
the  circulation. 

In  the  treatment  of  infectious  diseases,  such  as  typhoid 
fever,  pneumonia  and  empyema,  the  possibility  of  renal  infec- 
tion must  be  remembered,  and  efforts  made  to  prevent  its 
occurrence  by  the  use  of  urinar}^  antiseptics,  such  as  hexa- 
methylene-tetramin  (urotropin)  and  the  ing'estion  of  as 
large  quantities  of  water  as  possible,  without  taxing  too 
much  the  water  excreting  power  of  the  kidneys.  In  any 
condition  where  catheterization  of  the  bladder  becomes  neces- 
sary, every  possible  precaution  to  secure  asepsis  must  be 
made.  If  cystitis  occurs,  it  should  be  actively  treated  as  a 
source  of  great  danger,  and  the  use  of  ordinary  antiseptics 
and  the  drinking  freely  of  water  are  the  important  prophy- 
lactic measures  to  be  followed  in  combating  this  complication. 
Catheterization  of  the  ureters  must  not  be  undertaken  lightly, 
and  in  the  performance  extreme  care  must  be  taken  to  avoid 
infection.  A  calculus  in  the  kidney  is  always  a  source  of 
danger.  It  may  injure  the  contiguous  renal  structures,  and 
so  create  a  local  point  of  diminished  resistance  that  invites 
infection.    It  should,  therefore,  be  removed. 

When  the  kidney  or  its  pelvis  has  been  infected,  an 
attempt  is  made  to  destroy  the  ofTending  organisms  and  to 
raise  the  resistance  of  the  patient.  The  administration  of 
urinary  antiseptics,  of  which  hexamethylene-tetramin  (uro- 
tropin), 5-grain  (0.32  Gm.)  doses,  three  or  four  times  daity, 
is  strongly  indicated.  In  the  majority  of  cases  this  drug  is 
without  harmful  effect,  but  in  a  few  cases  hematuria  and 
strangury  occur.  If  these  s^^mptoms  appear  in  the  course  of 
a  pyogenic  infection  of  the  kidneys,  the  drug  must  be  with- 
drawn for  a  few  days  in  order  to  determine  the  origin  of  the 
symptoms.  Should  the  hematuria  be  the  result  of  the  taking 
of  hexamethylene-tetramin  (urotropin),  much  harm  will  be 
done  to  the  kidneys  by  its  continuance. 

It  is  probable  that  bacteria  which  will  grow  in  an  acid 
urine,  will  grow  less  well,  or  even  die,  in  an  alkaline  medium. 
The  converse  may  be  said  of  bacteria  growing  well  in  alkaline 
urine.    Therefore,  the  reaction  of  the  urine  should  be  changed. 


PYOGENIC   INFECTION.  631 

Boric,  benzoic,  salicylic  or  camphoric  acids  should  be  given 
when  the  urine  is  alkaline;  if  acid,  alkaline  waters,  sodium 
bicarbonate,  potassium  citrate  or  acetate  should  be  used. 

Diet  is  important,  and  must  be  arranged  to  suit  the  in- 
dividual case.  The  patient  must  he  adequately  nourished  in 
order  to  raise  his  resistance  to  the  disease.  Even  though 
fever  be  present,  the  diet  must  be  as  generous  as  the  diges- 
tion will  tolerate.  A  strict  milk  diet  is  to  be  avoided.  As  a 
rule,  a  mixed  diet,  with  a  minimum  of  protein,  70  to  80  Gms. 
(2.2  to  2.5o  ),  is.  best.  Alcohol  should  be  avoided.  Water 
should  be  drtmk  freely,  the  amount  ingested  depending  upon 
the  ability  of  the  kidneys  to  excrete  water. 

As  a  rule  the  pain  is  not  of  sufficient  severity  to  call  for 
medication.  Hot  stupes  or  hot-water  bottles,  applied  to  the 
lumbar  region,  often  relieve  the  aching.  When  pain  becomes 
an  annoying  symptom,  acetylsalicylic  acid  (aspirin),  5  to  10 
grains  (0.32  to  0.6  Gm.),  or  acetphenetidin,  5  to  10  grains 
(0.32  to  0.6  Gm.),  may  be  employed.  For  severe  pain  it  may 
be  necessary  tO'  use  codein  or  morphin. 

When  possible,  a  bacteriological  study  of  the  urine  must 
be  made,  with  a  view  of  isolating  the  ofifending  organism, 
from  which  to  make  a  vaccine.  If  more  than  one  micro- 
organism be  present,  a  polyvalent  vaccine  should  be  made 
containing  the  various  germs  in  their  numerical  relationships  as 
found  in  the  culture.  About  fifty  million  bacteria  should  be 
given  as  the  first  dose.  The  next  dose  should  be  increased 
or  decreased,  depending  upon  the  presence  or  absence  of  a 
reaction  and  its  severity.  They  should  be  administered  hypo- 
dermically  at  intervals  of  from  five  to  seven  days.  Stock 
vaccines  should  not  be  used. 

Operation  must  be  resorted  to,  if  the  constitutional  symp- 
toms are  severe,  and  particularly  if  the  patient  shows  increas- 
ing evidence  of  toxemia.  It  must,  likewise,  be  resorted  to 
in  the  absence  of  severe  constitutional  symptoms,  if  the 
patient  be  gradually  losing  weight  and  strength.  Before 
operating  it  is  imperative  to  catheterize  the  ureters  to  deter- 
mine definitely  whether  one  or  both  kidneys  are  diseased,  and 
to  study  the  functional  activity  of  each  kidney  with  the 
phenolsulphonephthalein  test.  Thus  we  are  able  to  deter- 
mine,   not   only   which    kidney   is   diseased,    but,   if  both    are 


632  DISEASES   OF   THE   KliDNEYS. 

affected,  which  one  the  more  seriously.  With  this  knowledge 
it  will  not  happen  that  the  better  of  the  two  kidneys  is 
removed,  resulting  in  the  speedy  death  of  the  patient.  The 
removal  of  an  infected  kidne}^  is  frequently  followed  by  a 
marked  increase  in  the  functional  power  of  the  remaining  one. 

PERINEPHRITIC  ABSCESS. 

By  this  is  meant  suppuration  in  the  connective  tissue  sur- 
rounding the  kidneys.  The  abscess  is  practically  always 
secondary  to  infection  elsewhere,  usually  in  the  kidney  or  its 
pelvis.  Rarely  the  source  may  be  in  some  of  the  neighbor- 
ing structures.  A  primary  infection  is  conceivable,  but  this 
is  so  rare  as  to  be  negligible.  In  a  series  of  cases  studied  by 
Braasch^s  the  etiologic  factors  in  the  order  of  their  frequency 
were  (1)  pyonephritis ;  (2)  renal  tuberculosis;  (3)  nephroli- 
thiasis; (4)  abscess  of  the  renal  cortex,  and  (5)  traumatic 
rupture  of  the  kidney. 

The  symptom  of  first  importance  is  pain,  sometimes  in- 
creased by  pressure,  in  the  upper  lateral  aspect  of  the  abdo- 
men or  in  the  lumbar  region.  Chills,  fever  and  sweats,  or 
chilliness,  with  fever  of  the  continued  type,  occur.  Edema  of 
the  skin  over  the  afifected  area  is  observed  in  some  of  the 
cases.  If  the  disease  be  of  sufficiently  long  duration,  emacia- 
tion eventual^  sets  in.  The  leucocytes,  particularly  the 
polynuclears,  are  usualty  very  much  increased.  AVhen  the 
abscess  is  the  result  of  infection  from  the  kidney,  pus  and 
blood  may  be  found  in  the  urine,  sometimes  in  microscopic 
quantities  only.  As  the  pus  cells  and  erythrocj^tes  may  be 
present  intermittently,  repeated  examinations  of  the  urine  are 
necessary.  Bacteriologic  examination  of  the  urine  collected 
separately  from  each  kidney  often  yields  valuable  informa- 
tion. A  cystoscopic  examination  must  be  made  and  the  urine 
from  each  kidney  separately  examined  for  abnormal  con- 
stituents. A  functional  test  of  each  kidney  is  essential,  inas- 
much as  the  results  of  such  an  inquiry  help  to  determine  the 
nature  of  the  surgical  treatment  to  be  followed.  For  the 
same  reason  the  kidney  and  its  pelvis  should  be  studied  with 
the  ^-ray. 

The  treatment  consists  in  evacuating  the  pus.  Whether 
the  abscess  be  simply  drained  or  a  nephrectomy  performed  is 


TUBERCULOSIS    OF   THE    KIDNEY.  633 

dependent  on  the  state  of  the  kidney  as  diagnosed  by  a  study 
of  the  urine,  in  'conj unction  with  the  ;ir-ray  studies.  If  the 
kidney  be  tuberculous  or  a  pyonephrosis  be  present,  the  organ 
should  be  removed,  provided  that  the  opposite  kidney  is 
functionating  properly.  If  the  source  of  the  pus  consists  of 
a  superficial  abscess  in  the  renal  cortex,  simple  drainage  of 
the  perirenal  abscess  will  usually  eiTect  a  cure. 

TUBERCULOSIS  OF  THE  KIDNEY. 

The  kidney  may  be  affected  by  tuberculosis  to  the  almost 
complete  exclusion  of  other  parts  of  the  body,  or  the  renal 
lesion  may  be  merely  part  and  parcel  of  a  general  miliary 
tuberculosis.  In  the  latter  event  the  diagnosis  is  made  with 
difficulty,  if  at  all,  and  there  is  no  treatment  directed  to  the 
renal  infection  that  is  of  any  value.  The  renal  disease  is  but 
a  detail  in  the  general  picture. 

The  kidney  is  probably  never  the  seat  of  primary  tuber- 
culosis. In  almost  every  instance  the  infection  is  carried  to 
the  kidney  from  a  focus  elsewhere  in  the  body,  the  primary 
site  of  which  may  be  a  slight  infection  at  the  apex  of  a  lung, 
or  a  diseased  peribronchial,  or  a  mediastinal  or  mesenteric 
lymph  gland.  Infection  may  occur  from  the  bladder  or  other 
parts  of  the  genito-urinary  system  (urogenotis  or  ascending 
infection),  but  this  is  probably  very  much  less  common  than 
hematogenous  infection.  Very  rarely  infection  may  occur  by 
contiguity,  as  from  the  adrenal,  or  the  intestine.  As  a  rule, 
but  one  kidney  is  affected,  the  right  probably  more  often  than 
the  left.  The  disease  may  occur  at  any  age,  but  is  most  com- 
mon between  the  ages  of  20  and  40  years. 

The  pathologic  changes  that  take  place  in  the  kidney  are 
the  same  as  those  that  occur  in  any  other  part  of  the  body 
infected  with  tubercle  bacilli.  Small  grayish  tubercles  ap- 
pear, their  location  depending  upon  the  point  where  the  first 
invaders  lodge.  The  primary  tubercles  may,  therefore,  be 
found  in  the  neighborhood  of  the  Malpighian  bodies,  in  the 
uriniferous  tubules,  in  the  pyramids,  or  in  the  papillae.  Usu- 
ally the  infection  occurs  in  the  pyramids.  The  minute  tuber- 
cles grow  larger,  caseate,  often  coalescing  to  form  large 
necrotic  areas  which  ulcerate  into  the  renal  pelvis  and  dis- 
charge  the   pus    into   the   urine,   leaving  large   cavities   that 


634  DISEASES    OF    THE    KIDNEYS. 

extend  deeply  into  the  renal  substance.  Secondarily,  in  such 
cases,  the  renal  pelvis,  ureter,  bladder,  and  other  parts  of  the 
genito-urinary  system  become  infected.  The  kidney  may 
remain  about  normal  in  size,  unless  occlusion  of  the  ureter 
takes  place,  in  which  event  pyonephrosis  develops  and  the 
kidney  may  become  a  large  sac  filled  with  caseous  material. 
The  occlusion  of  the  ureter  may  result  in  a  disappearance  of 
pus  from  the  urine  and  add  to  the  difficulty  of  diagnosis  of 
cases  coming  under  observation  for  the  first  time  after  the 
occlusion  has  occurred.  A  cystoscopic  examination  will  aid 
very  greatly  in  making  a  diagnosis.  Late  in  the  disease  the 
surrounding  tissue  and  the  opposite  kidney  may  become 
infected.  The  tuberculous  abscess  ma}^  extend  through  the 
renal  substance,  and,  rupturing  the  capsule,  may  burrow  out- 
ward and  discharge  upon  the  surface  of  the  body,  or  may 
extend  into  the  peritoneum,  and,  consequently,  infect  the 
entire  abdominal  cavity. 

Unfortunately  in  the  early  stage  of  the  disease,  when  an 
accurate  diagnosis  is  of  the  utmost  importance,  the  absence 
or  vagueness  of  the  symptomatology  renders  an  unqualified 
diagnosis  most  difficult.  Symptoms  may  be  absent  until  late 
in  the  disease,  in  many  cases ;  in  others  a  very  gradual  loss 
of  weight  with  malaise  and  slight  weakness  may  be  the  only 
symptoms.  The  urinary  changes  are  the  earliest  and  most 
constant,  and  of  these,  the  appearance  of  blood  is  the  most 
important.  The  hemorrhage  may  be  so  slight  as  to  be 
detected  only  by  the  microscope,  but  when  found  should 
always  raise  the  question  of  tuberculosis.  Later  when  casea- 
tion occurs,  pus  may  appear  in  the  urine  microscopically^  or 
macroscopically,  and  casts  ma}^  occur.  The  macroscopic 
appearance  of  pus  may  be  intermittent,  although  in  many- 
cases  it  is  absent  throughout  the  course  of  the  disease. 
Sometimes  tubercle  bacilli  may  be  found.  Their  absence 
from  the  sediment  does  not  exclude  the  diagnosis  of  renal 
tuberculosis.  The  reaction  of  the  urine  is  acid,  unless  an 
associated  infection  with  a  pyogenic  organism  occurs,  in 
which  case  the  urine  is  alkaline,  and  deposits,  on  standing,  a 
heavy  sediment  of  pus,  mucus  and  phosphates.  The  quan- 
tity of  urine  in  24  hours  is  likely  to  be  normal,  though  it  may 
be  either  increased  or  decreased.     Commonly  patients  com- 


TUBERCULOSIS    UK    THE    KJDNEY.  635 

plain  of  frequent  micturition  at  night.  Pain  may  occur  during- 
the  act  of  micturition,  even  when  cystitis  is  absent. 

A  dull  ache  is  sometimes  felt  in  the  lumbar  regions,  but 
as  a  rule  it  is  slight.  If  a  plug  of  caseous  material  or  a 
blood-clot  lodges  in  the  ureter,  severe  colicky  pains,  as  in 
nephrolithiasis,  may  occur.  Fever  may  be  absent  until  late 
in  the  disease,  when  the  evidences  of  a  marked  sepsis,  chills, 
fever  and  sweats  may  be  a  conspicuous  clinical  feature.  As 
a  rule,  the  temperature  is  subnormal  during  the  day  and  at 
night  ascends  to  100°  F.  {7>7.7°  C),  or  slightly  less.  Night 
sweats  may  occur. 

Ph3^sical  examination  may  reveal  tenderness  on  pressure 
in  the  lumbar  region  or  loin.  As  a  rule,  no  mass  is  felt,  but 
when  a  pyonephrosis  is  present  the  kidney  may  be  palpable, 
and  is  usually  found  to  be  very  tender.  The  size  of  the  pal- 
pable kidney  may  vary  from  time  to  time,  depending  upon 
the  patency  of  the  ureter.  If  pus  has  accumulated  in  the 
perirenal  and  pararenal  tissues,  edema  in  the  loin  or  lumbar 
region  may  be  present. 

Because  of  the  importance  of  early  diagnosis  and  the 
untrustworthiness  of  general  symptoms  of  renal  tuberculosis, 
the  finding  of  blood  in  the  urine,  either  in  microscopic  or 
macroscopic  amounts,  calls  for  a  thorough  investigation, 
including  a  cystoscopic  examination  and  catheterization  of 
the  ureters.  Occasionally  a  whitish  mass,  cheese-like  in  con- 
sistence and  moulded  to  the  shape  of  the  ureter,  may  be  seen 
emerging  from  the  mouth  of  the  ureter  by  means  of  the 
cystoscope.  The  urine  thus  obtained  should  be  painstakingly 
examined  for  tubercle  bacilli,  which,  if  found,  are  of  extreme 
importance  in  the  diagnosis,  unless  there  is  widespread  tuber- 
culosis in  other  parts  of  the  body,  in  which  event  they  com- 
monly find  their  way  into  the  urine  without  producing  lesions 
that  are  recognizable  by  the  naked  eye.  Catheterization  of 
the  ureter,  filling  the  ureter,  pelvis  and  calices  of  the  kidney 
with  thorium,  followed  by  a  radiographic  or  fluoroscopic 
examination,  often  aids  the  diagnosis.  The  cheese-like  ma- 
terial may  be  injected  into  a  guinea  pig,  so  that  the  tulier- 
culous  character  may  be  proven. 

In  the  vast  majority  of  instances  surgical  treatment  is 
necessary.      The    operations    which    may    be    considered    are 


636  DISEASES    OF   THE    KIDNEYS. 

nephrectomy,  nephrotomy,  nephrostomy  and  partial  resection 
of  the  kidney.  Nephrectomy  is  the  operation  of  choice. 
Statistics  of  various  surgeons  show  a  good  number  of  cures. 
The  mortality  rate,  which  was  formerly  from  20  per  cent,  to 
25  per  cent.,  has  been  reduced  to  10  per  cent.  The  statistics 
of  some  clinics  show  the  mortality  rate  to  be  as  low  as  3  per 
cent.  Of  nephrotomized  cases,  Brown^^  states  that  of  a  series 
of  72  cases  from  different  surgical  clinics,  7  were  cured  com- 
pletely, 18  had  a  persistent  fistula,  28  required  a  secondary 
nephrectomy,  and  21  died.  In  this  series,  therefore,  the  mor- 
tality rate  was  extremely  high,  and  is  in  marked  contrast  to 
the  10  per  cent,  rate  in  nephrectomy.  Partial  resection  of 
the  kidney  is  inadvisable,  for  the  reason  that  some  diseased 
tissue  may  be  left  behind  to  act  as  the  focus  for  further 
trouble. 

Before  nephrectomy  is  done  it  is  absolutely  imperative  to 
ascertain  the  health  of  the  opposite  kidney,  and  likewise  its 
functional  capacity.  For  this  purpose  the  ureters  must  be 
catheterized,  and  the  urine  of  the  presumably  sound  kidney 
studied  clinically  and  microscopically.  The  presence  of  a 
small  amount  of  albumin  unaccompanied  by  pus  or  blood  is 
not  a  contraindication  to  operation.  If  the  phenolsulpho- 
nephthalein  test  repeatedly  shows  the  functional  capacity  to 
be  considerably  impaired,  a  nephrectomy  must  not  be  under- 
taken. A  slight  impairment  as  shown  by  the  test  is  not  a 
contraindication  to  operation,  as  often,  after  operation,  the 
function  of  the  remaining  kidney  increases  quite  naturally. 
Marked  retention  in  the  blood  of  urea  or  of  creatinin  indi- 
cates serious  renal  inefficiency  and  contraindicates  the  opera- 
tion. Surgery  should  not  be  attempted  when  there  is  exten- 
sive tuberculosis  elsewhere  in  the  body. 

If  the  patient  can  be  kept  under  close  observation  and 
control,  and  if  the  tuberculosis  of  the  kidney  is  not  extensive, 
an  effort  may  be  made  to  secure  improvement  by  non-surgical 
measures.  The  effort,  however,  must  not  be  prolonged.  If 
definite  improvement  is  not  secured  after  two  months'  treat- 
ment or  if  at  the  end  of  two  weeks'  treatment  the  patient  is 
worse,  even  though  but  to  a  slight  degree,  surgical  interfer- 
ence must  not  be  postponed 


TUBERCULOSIS    OF   THE   KIDNEY.  637 

The  non-surLjical  treatment,  both  l)efore  and  after  the 
operation,  must  be  condueted  along  the  Hnes  generally 
adopted  for  tul^erculosis  elsewhere  in  the  body.  Of  the 
measures  employed  the  most  important  are  the  hygienic  and 
dietetic.  The  skin  must  be  kept  in  g-ood  condition,  in  order 
to  maintain  its  function  as  an  excretory  organ  at  the  highest 
level.  For  this  a  warm  cleansing  bath,  using  a  bland  soap, 
such  as  castile,  should  be  taken  at  least  three  times  a  week, 
preferably  at  night  just  before  retiring.  If  taken  during  the 
day  the  patient  must  remain  indoors  for  an  hour  or  two  to 
avoid  chilling.  If  the  skin  be  dry  and  harsh,  gentle  massage 
with  equal  parts  of  cocoa  butter  and  lanolin,  with  sufficient 
almond  oil  to  make  the  mixture  of  the  consistency  of  soft 
butter,  is  of  value.  The  patient  should  be  trained  in  the  use 
of  cold  baths,  which  can  best  be  done  by  ordering  a  sponge 
bath  of  tepid  water  each  morning  upon  arising.  The  tem- 
perature of  the  water  should  be  lowered  a  degree  each  morn- 
ing or  two  until  a  cold  bath  is  being  taken.  This  bath  should 
be  followed  by  a  brisk  rub  with  a  coarse  Turkish  towel. 

Sunlight  is  very  important.  The  patient  should  sit  in  the 
sun  with  the  head  covered  by  a  hat  or  by  a  small  sunshade. 
In  cool  or  cold  weather  almost  all  the  hours  of  sunlight  may 
be  utilized.  In  hot  weather  only  certain  hours  in  the  early 
morning-  and  in  the  evening  may  be  used.  Colored  glasses 
may  be  worn  to  protect  the  eyes  from  the  glare.  As  much 
time  as  is  possible  should  be  spent  out-of-doors  in  a  comfort- 
able reclining  chair  on  a  veranda,  sheltered  from  the  wind. 
If  the  air  be  chilly  or  cold,  woolen  underwear  should  be  worn 
and  sufficient  blankets  used  to  keep  out  the  cold.  The  dan- 
ger of  renal  congestion  from  chilling  of  the  body  surface  must 
always  be  remembered. 

Patients  who  have  recovered  sufficiently  from  the  imme- 
diate effects  of  the  operation,  and  who  can  afford  to  do  so, 
should  seek  a  climate  in  which  the  spending-  of  a  maximum 
amount  of  time  out-of-doors  is  possible.  The  climate  best 
suited  to  these  patients  is  to  be  found  in  southern  California, 
Arizona,  New  Mexico,  Utah,  Colorado  and  Hawaii. 

There  are  a  number  of  factors  to  be  considered  in  advis- 
ing climatic  treatment,  one  of  the  most  important  being  the 
character  of  the   food  supply   to   be   obtained   at  the   resort 


638  ,  DISEASES    OF   THE   KIDNEYS. 

selected.  Much  better  results  will  be  secured  at  home,  in  a 
poor  climate,  with  a  properly  arranged  dietary  of  good  foods, 
than  can  be  possible  in  an  ideal  climate  with  improperly 
cooked  foods  of  poor  quality. 

Rest,  both  mentally  and  physically,  should  be  insisted 
upon  in  the  beginning.  All  business  cares,  household  worries, 
anxieties  of  every  kind  must  be  removed  as  far  as  possible. 
Most  of  the  day  should  be  spent  in  a  recumbent  or  semi- 
recumbent  posture,  and  ten  consecutive  hours  should  be 
spent  in  bed,  e.g.,  9  p.m.  to  7  a.m.  The  amount  of  exercise 
permitted  varies  with  the  strength  of  the  patient  and  the 
effect  upon  the  kidney.  Fatigue  is  to  be  avoided  alwa3^s. 
The  appearance  of  albuminuria,  or,  if  present,  its  increase 
after  exercise,  is  an  evidence  of  harm.  Very  active  exercise, 
such  as  tennis,  rowing,  running,  climbing,  must  be  pro- 
hibited. Walking,  the  distance  increased  as  the  patient's 
strength  increases,  is  the  best  form  of  exercise.  Late  in  con- 
valescence, golf  may  be  played,  but  no  efforts  in  competition, 
such  as  match  plays,  must  be  undertaken.  Before  the  patient 
is  strong  enough  to  exercise,  the  muscles  may  be  kept  in  a 
semblance  of  condition  by  general  massage. 

The  diet  must  be  arranged  in  accordance  with  the  func- 
tional capacity  of  the  kidneys.  The  proteins  in  the  diet 
should  never  exceed  the  needs  of  the  normal  adult,  80  to  100 
Gms.  (2.5  to  3.2  oz.),  even  when  the  number  of  calories  per 
day  is  greatly  increased.  If  uric  acid,  urea  or  creatinin  reten- 
tion in  the  blood  rises,  the  amount  of  proteins  must  be  re- 
duced. For  the  average  case  a  mixed  diet  of  plain,  easily 
digested  foods  should  be  arranged.  A  glass  of  milk,  or  milk 
and  eggs  flavored  to  suit  the  taste  of  the  patient,  may  be  taken 
between  breakfast  and  lunch,  and  between  lunch  and  dinner. 
The  amount  of  fluid  depends  entirely  upon  the  ability  of  the 
kidney  to  excrete  water,  the  chief  object  being  always  to 
secure  the  elimination  of  48  ounces  (1419  mils)  of  urine  daily 
in  an  adult. 

The  value  of  the  use  of  tuberculin  has  not  been  conclu- 
sively demonstrated.  Its  use  is  not  without  danger,  and  in 
the  present  state  of  our  knowledge  it  is  inadvisable  to  recom- 
mend its  use  in  general  practice. 


CYSTIC    DEGENERATION    OF   THE    KIDNEYS.  639 

TUMORS  OF  THE  KIDNEY. 

Tumors  of  the  kidney  are  not  very  common,  and  often  pre- 
sent great  difficulties  in  diagnosis.  Among  the  new  growths 
that  affect  the  kidney  are  hypernephroma,  carcinoma,  sarcoma 
and  adenoma.  The  cardinal  symptoms  of  renal  tumor  are 
hematuria,  pain  and  tumor.  When  all  these  are  present  the 
neoplasm  probably  has  grown  to  great  size.  New  growths, 
when  located  at  the  upper  pole  of  the  kidney,  may  attain  con- 
siderable size,  and  yet  not  be  palpable.  The  pain  is  often 
absent  and  when  present  is  extremely  variable  in  its  charac- 
ter, and  not  at  all  diagnostic.  It  may  vary  from  a  dull  ache 
in  the  lumbar  region  to  severe  neuralgic  pains  along  the 
course  of  the  sacral  and  pelvic  nerves.  If  blood-clots  lodge 
in  the  ureter,  pain  similar  to  that  experienced  in  nephroli- 
thiasis -occurs.  As  a  rule,  the  hematuria  is  intermittent.  It 
may  be  observed  in  but  a  few  specimens  of  urine  or  may  per- 
sist for  days.  The  very  sudden  disappearance  of  blood  from 
the  urine  may  be  due  to  the  blockage  of  the  ureter.  As  the 
different  tumors  of  the  kidney  present  no  symptoms  that 
point  to  their  identity,  it  is  usually  impossible  to  differentiate 
them  clinically.  It  is  to  be  remembered  that  sarcoma  of  the 
kidney  and  tumors  arising  from  the  inclusion  of  embryonal 
tissue  in  the  renal  substance  occur  in  early  life.  The  other 
neoplasms  are  more  likely  to  occur  after  the  age  of  30  years, 
the  majority  being  found  between  the  ages  40  and  60  years. 

The  most  important  function  of  the  physician  is  the  diag- 
nosis of  the  presence  of  a  renal  tumor  as  early  as  possible, 
and  in  this  attempt  all  cases  of  hematuria  should  be  studied 
with  care,  and  the  real  cause  of  the  blood  determined.  It  is 
not  sufficient  to  surmise  a  cause.  There  is  no  medical  treat- 
ment. In  the  light  of  our  present  knowledge,  there  is  no 
drug  or  combination  of  drugs  that  will  "cure"  the  patient  of 
a  renal  tumor.  When  possible  the  tumor  should  be  removed 
surgically. 

CONGENITAL  CYSTIC  DEGENERATION 
OF  THE  KIDNEYS. 

This  is  a  rare  affection,  probably  due  to  developmental 
error.     The   kidneys  become   very   greatly   increased   in   size 


640  DISEASES    OF    THE    KIDNEYS. 

and  appear  to  be  composed  entirely  of  an  aggregation  of  cysts 
of  varying  size.  The  growth  of  the  renal  cysts  in  the  fetus 
may  be  so  great  as  to  prevent  its  passage  through  the  birth 
canal.  The  cysts  may  not  be  large  at  birth,  but  later  grad- 
ually increase  in  size,  so  that  the  patient  dies  in  adult  life 
because  of  renal  insufficiency.  Both  kidneys  are  usually 
affected,  and  cysts  may  also  be  found  in  the  liver.  Treat- 
ment is  of  no  avail,  the  patient  dying  eventually  of  uremia. 

BIBLIOGRAPHY. 

1.  Sahli :    Diagnostic  Methods,  German  Ed.  4,  English  Trans.,  Phila- 
delphia,  1905. 

2.  Ibid. 

3.  Die  Erkrankungen  der  Nieren,  Berlin,  1902;  also  Nothnagel's  En- 
cyclopedia of  Practical  Medicine,  American  Ed.,  Philadelphia,  1905. 

4.  MacCallum,  W.  G. :    A  Textbook  of  Pathology,  Philadelphia,  1916. 

5.  A  Fatal  Case  of  Poisoning  by  Bichloride  of  Mercury,  Bull.  Med.- 
Chir.  College,  Philadelphia,  1914,  x,  5. 

6.  Billings :     Forchheimer's    Therapeusis    of    Internal    Diseases,    New- 
York  and  London,  iv,  40. 

7.  Jour.  Pharmacol,  and  Exper.  Therap.,  1910,  i,  579. 

8.  Arch.  Int.  Med.,  1915,  xvi,  733. 

9.  Jour.  Am.  Med.  Assn.,  1916,  Ixvii,  929. 

10.  Arch.  Int.  Med.,  1916,  xvii,  570. 

11.  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  1234. 

12.  Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,  Mayo  Clinic, 
1905-1909,  Philadelphia,  1911. 

13.  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  1234. 

14.  Mayo,  W.  J.,  Braasch,  W.  F.,  and  MaCarty,  W.  C:  Relation  of 
Anomalous  Blood-vessels  to  Hydronephrosis,  Jour.  Am.  Med.  Assn., 
1909,  iii,  1383. 

15.  Surg.,  Gynec,  and  Obstet.,   1915,  xxi,  631. 

16.  Osier,  William :    Modern  Medicine,  1909,  vi,  296. 


Diseases  of  the  Digestive  System 


The  Mouth,         The  Esophagus. 
The  Stomach. 


B.    B.   VINCENT   LYON,    A.B.,    M.D, 

Chief  of  Clinic,   Gastro-enterological   Department,  Jefferson   Hospital; 

Pathologist,  Methodist  Episcopal  Hospital,   Philadelphia. 


The  Intestines.         The  Liver. 
The  Pancreas. 

BY 

LOUIS    LEHRFELD,    A.M.,    M.D., 

Editor  of  the  "Monthly  Bulletin"  and  Agent  for  the  Prevention  of 
Disease,  Department  of  Public  Health  and  Charities,  Philadelphia; 
Secretary,  Pneumonia  Commission,  Philadelphia;  formerly  Assist- 
ant Surgeon  United  States  Navy. 


41 


(641) 


Diseases  of  the  Digestive  System. 


FOREWORD. 

In  the  section  on  Diseases  of  the  Digestive  System,  effort 
has  been  made  to  detail  such  treatment  as  may  be  within  the 
reach  of  the  average  practitioner.  A  brief  description  of  the 
pathology  and  etiology  has  also  been  given  in  order  to  make 
the  principles  of  treatment  more  comprehensive. 

Special  stress  has  been  laid  on  the  relation  of  mouth  infec- 
tions to  general  systemic  diseases.  Heretofore  the  average 
medical  practitioner  has  seemed  to  overlook  the  foci  of  infec- 
tion about  the  teeth,  tonsils,  and  sinuses  of  the  skull,  which 
are  now  known  to  be  actively  engaged  in  the  dissemination  of 
organic  diseases. 

Special  attention  is  also  given  to  the  subject  of  acute  infec- 
tious jaundice,  which  is  a  trench  disease  common  among  the 
troops  throughout  Europe.  This  infection  is  of  great  impor- 
tance to  the  Military,  Federal,  and  State  health  officials,  and 
has  therefore  been  reproduced  in  this  section  by  permission  of 
the  Surgeon-General  of  the  Public  Health  Service,  who  has 
recently  published  the  latest  information  on  this  subject 
matter. 

DISEASES  OF  THE  MOUTH. 

DISEASES    OF   THE   MOUTH   AS    RELATED    TO 
GENERAL    SYSTEMIC    DISEASES. 

It  is  only  within  recent  years  that  infections  of  the  mouth 
have  been  found  to  be  related  to  diseases  of  the  heart,  joints, 
muscles,  nerves,  stomach,  and  vascular  system.  These  infec- 
tions may  occur  about  the  teeth,  in  the  gums,  in  the  tonsils, 
and  in  the  various  bony  sinuses  of  the  skull  which  are  directly 
communicating  with  the  mouth.  The  anatomic  structure  of 
the  mouth  is  such  that  it  possesses  foss?e,  depressions,  crypts, 

(643) 


644  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

and  indentations,  which  may  become  hiding  places  for  the 
fertile  development  of  the  various  pathogenic  micro-organ- 
isms. Plere  they  lie  dormant  until  the  body  resistance  at  some 
time  or  other  is  lowered,  or,  in  symbiosis  with  other  micro- 
organisms, they  may  be  hastened  into  activity,  and  become 
disseminated  through  the  lymph  channels  or  by  the  blood  to 
other  tissues  in  the  body  for  which  they  have  special  affinity, 
and  there  produce  definite  lesions. 

It  is  now  known  that  certain  strains  of  pathogenic  bacteria 
have  the  special  qualification  of  selecting  definite  parts  of  the 
body  for  their  growth  and  development.  For  instance,  it  has 
been  demonstrated  that  certain  strains  of  streptococci  show 
special  affinity  for  joints,  tendons,  muscles,  and  valves  of  the 
heart.  Under  certain  other  conditions  the  same  streptococci, 
possessing  varj'ing  qualities  in  virulence  or  high  specificity, 
may  show  preference  for  the  gall-bladder,  the  appendix,  the 
stomach,  or  the  duodenum.  Inoculations  of  these  germs  into 
experimental  animals  have  produced  lesions  in  the  same  or- 
gans from  which  they  had  been  originally  taken.  This  re- 
markable discovery  has  given  new  light  and  impetus  along 
the  lines  of  biologic  therapy.  In  the  manufacture  of  vaccines 
for  the  treatment  of  these  various  infections  it  is  necessary 
not  onl}^  to  isolate  the  micro-organism  concerned,  but  that 
particular  type  of  germ  which  has  special  selection  for  dis- 
eased areas. 

Commercialized  dentistry  has  opened  the  way  for  the  faulty 
mechanical  dental  work  responsible  for  the  large  propor- 
tion of  mouth  infections  which  the  medical  profession  must 
deal  with  to-day.  Imperfectly  adjusted  cappings,  bridge  work, 
and  fillings  may  readily  favor  breeding  places  for  pathogenic 
micro-organisms.  Haphazard  dental  work  performed  b}^ 
various  commercial  dentists  has  given  the  medical  profession 
an  entirely  new  chain  of  diseases  to  deal  Avith,  nameh^  septic 
infections  in  the  mouth.  Undoubtedly  the  increased  attention 
given  by  the  public  to  the  care  of  teeth  has  decreased  the  per- 
centage of  digestive  disorders,  but  the  careless  correction  of 
defects  in  the  mouth  has  given  rise  to  focal  infections  which 
may  even  surpass  in  importance  the  original  defects  in  the 
teeth. 

Teeth  devitalized  in  the  course  of  treatment  by  the  dentist 


DISEASES  OF  THE  MOUTH.  645 

are  very  susceptible  to  infecting  agents,  and,  being  deprived 
of  the  nerve  supply,  inflammatory  conditions  may  occur,  even 
without  pain,  and  thus  be  overlooked  by  the  dentist  and  phy- 
sician ;  focal  pockets  of  purulent  material  may  accumulate 
under  crowns,  beneath  bridge  work,  or  at  the  roots  of  devita- 
lized teeth,  and  g'iv'e  no  local  symptoms.  Absorption,  how- 
ever, of  toxic  material  and  invasion  of  the  body  by  germs 
generated  at  these  pus  pockets  about  the  teeth  may  produce 
such  diseases  as  acute  articular  rheumatism,  chronic  arthritis, 
arthritis  deformans,  pericarditis,  endocarditis,  and  myocarditis. 
A  whole  chain  of  other  disease?  also  may  originate  from  these 
teeth  infections,  such  as  furunculosis,  myalgia,  anemia,  neph- 
ritis, gastritis,  and  enteritis.  Many  cases  of  ill-defined  dis- 
eases, such  as  neurasthenia,  melancholia,  physical  and  mental 
depression,  may  have  their  origin  in  purulent  infections  in  or 
about  diseased  teeth. 

The  tonsils  also  may  be  the  seat  of  hidden  pus  pockets, 
acting  as  distributing  foci  of  micro-organisms  lodged  in  struc- 
tures distant  from  the  original  seat  of  infection.  Thus,  acute 
articular  rheumatism,  pericarditis,  and  endocarditis  are  often 
traced  to  recurrent  attacks  of  sore  throat. 

The  mouth  also  is  subject  to  invasion  by  pathogenic  micro- 
organisms, because  of  its  intimate  connections  with  the  middle 
ear,  the  mastoid  sinuses,  the  ethmoid,  sphenoid  and  maxillary 
sinuses,  the  larynx,  the  esophagus,  and  the  lymphatics  of  the 
neck.  It  is  not  difficult  to  understand  that  these  various 
sinuses  and  organs  either  may  become  infected  through  the 
mouth  or  that  the  mouth  may  be  the  secondary  area  of  infec- 
tion subsequent  to  the  primary  invasion  of  the  organs  just 
named. 

Various  micro-organisms  may  be  found  in  the  mouth  of 
the  'healthy,  normal  individual.  The  salivary  secretions  with 
their  enz3^mes  are  sufficient  in  most  instances  to  stay  the  ac- 
tivity of  these  germs.  When,  however,  the  bodily  resistance 
is  lowered  through  disease,  local  or  systemic,  the  bacteria  in 
the  mouth  may  find  conditions  favorable  for  development  and 
invasion.  It  is  well  known  that  persons  may  carry  pathogenic 
bacteria  in  secretions  of  the  nose  and  throat,  and  that  they 
themselves  may  not  suffer  from  their  presence.  Thus  the 
streptococcus,  the  diphtheria  bacillus,  the  pneumococcus,  the 


646  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

influenza  bacillus,  and  the  meningococcus  have  been  isolated 
in  secretions  of  normal,  healthy  individuals.  It  is  only  when 
traumatism,  injury,  or  low  resistance  of  the  patient  exists  that 
these  germs  invade  the  body,  with  more  or  less  serious  results. 
Dalandi  in  discussing  oral  sepsis  makes  the  following  con- 
clusions on  this  subject: 

1.  Focal  infection  is  one  of  the  causes  of  acute  and  chronic 
arthritis,  periarthritis,  arthritis  deformans,  ostitis,  endocar- 
ditis, pericarditis,  or  myocarditis,  endarteritis,  phlebitis,  acute 
and  chronic  parenchymatous  nephritis,  cholecystitis,  chole- 
lithiasis, gastric  and  duodenal  ulcer,  appendicitis,  meningitis, 
thyroiditis,  neuritis,  oophoritis,  cerebritis,  myelitis,  ocular  dis- 
eases and  furunculosis,  and  is  the  unrecognised  cause  of  other 
diseases. 

2.  The  results  of  focal  infection  are  due  to  the  variety  and 
varying  virulence  of  the  micro-organisms,  the  duration  of  the 
focus,  the  quantity  of  micro-organisms  and  toxins  entering 
the  circulation,  the  rapidity  of  absorption,  the  integrity  of  the 
tissues,  and  the  susceptibility  or  immunity  of  the  patient.  The 
virulence  of  the  micro-organism,  rather  than  the  size  of  the 
lesion,  is  important.  Although  the  exact  effects  of  toxemia 
are  not  fully  understood,  it  plays  an  important  role  in  focal 
infection. 

3.  The  usual  location  of  focal  infection  is  in  the  head  cavi- 
ties, the  order  of  frequency  being*  the  mouth,  the  tonsils,  and 
the  sinuses.  The  diagnosis  of  chronic  focal  infection  is  some- 
times easy,  but  more  often  it  is  difficult.  A  common  error  is 
to  recognize  but  one  focus  when  more  than  one  exists,  and 
this  is  especially  true  of  the  teeth. 

Freudenberger,2  in  commenting  on  the  relation  of  the  teeth 
to  tuberculosis,  in  a  study  of  297  cases.,  claims  that  it  is  a 
question  whether  tuberculous  disease  and  mixed  infection 
among  his  patients  arose  through  the  condition  of  their  teeth 
and  gums,  or  whether  their  tuberculous  condition  affected 
their  teeth  and  gums  secondarily.  It  is  assumed,  at  any  rate, 
that  a  bad  condition  of  the  teeth  and  gums  offers  a  good 
medium  for  the  growth  of  the  tubercle  bacillus,  which  has 
often  been  found  in  teeth  containing  cavities.  Sore  teeth  and 
tender  gums,  however,  may  be  the  cause  of  insufificient  and 
ineffectual  mastication. 


DISEASES  OF  THE  MOUTH.  647 


TREATMENT. 


Affections  of  the  joints,  indefinite,  vague,  general  symp- 
toms, and  cardiac  disease  usually  call  for  inspection  of  the 
mouth.  Very  often  no  local  lesion  is  visible.  Palpation  of  the 
gums  and  teeth  may. locate  areas  of  tenderness.  The  tonsils 
may  be  perfectly  clean  on  the  surface,  free  from  accumulations 
of  cryptic  secretions,  and  present  no  evidence  of  disease,  yet 
beneath  the  surface  there  may  be  distinct  definite  pus  pockets. 
The  history  of  repeated  attacks  of  tonsillitis  may  lead  to  the 
suspicion  of  hidden  areas  of  infection.  Each  tooth  should  be 
tapped  by  a  metal  instrument  to  determine  the  presence  or 
absence  of  .pain.  It  may  be  necessary  to  have  the  consultation 
of  a  dentist  for  the  determination  of  carious  or  diseased  teeth. 
Even  after  all  this  inspection,  there  may  be  no  visible  evidence 
of  disease.  If  the  suspicion,  however,  is  strong  that  infection 
exists  about  the  roots  of  the  teeth,  an  jr-ray  examination  is  iu 
order.  Roentgenologists  state  that  in  some  instances  the 
greatest  detail  in  the  taking  of  pictures  often  fails  to  show  pus 
pockets,  which  do  not  throw  shadows  of  diseased  roots. 

Every  case  of  infection  about  the  teeth  and  gums  should 
be  referred  to  a  competent  dentist.  The  usual  application  of 
tincture  of  iodin  by  the  medical  practitioner  is  not  sufficient. 
Pus  pockets  should  be  opened  and  drained  just  as  similar  surg- 
ical conditions  in  other  parts  of  the  body. 

There  has  been  a  common  tendency  on  the  part  of  physi- 
cians to  recommend  the  extraction  of  teeth  where  diseased 
gums  and  purulent  infection  exist.  This  haphazard  recom- 
mendation is  condemned  on  the  grounds  that  pus  pockets  may 
be  opened,  curetted,  and  successfully  drained,  without  neces- 
sarily requiring  the  removal  of  teeth.  This  does  not  hold  true, 
however,  in  all  cases,  such  as  in  pyorrhea  of  long  standing, 
when  extraction  gives  more  speedy  results  and  an  early  abate- 
ment of  symptoms.  I  have  in  mind  a  special  case  of  cardio- 
renal  disease  in  which  medication  accomplished  no  results  un- 
til all  of  the  teeth,  both  upper  and  lower,  in  a  patient  of  middle 
age,  were  extracted.  In  this  instance  pyorrhea  alveolaris, 
carious  teeth,  and  ulcerative  stomatitis  were  present. 

As  a  general  mouth-wash,  liquor  antisepticus  alkalinus  is 
recommended  in  mouth  infections.     Listerine  and  peroxid  in 


648  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

equal  parts  are  also  valuable.  In  the  absence  of  these,  potas- 
sium permanganate  in  solution  (1 :  500)  may  also  be  used. 

Diseased  tonsils  call  for  early  removal.  Repeated  attacks 
of  tonsillitis  indicate  that  there  is  a  focal  infection  present, 
which  is  lighted  up  from  time  to  time.  It  is  advisable  that  the 
tonsils  be  removed  during  an  interval  of  these  attacks.  Partial 
tonsillectomies,  in  which  stumps  of  tissue  remain  between  the 
pillars  of  the  fauces,  may  continue  to  act  as  foci  of  infection. 
It  is,  therefore,  advisable  that  diseased  tonsils  be  removed 
completely.  I  have  frequently  met  with  cases  of  tonsillitis  in 
patients  who  claimed  that  their  tonsils  were  removed  in  child- 
hood. Hypertrophy  of  the  stumps  may  take  place,  and  be- 
come subject  to  invasion  as  in  the  original  tonsil. 

Sinusitis  and  middle  ear  disease  very  often  have  their 
origin  of  infection  in  the  mouth.  For  the  treatment  of  these 
conditions  appropriate  textbooks  on  these  subjects  should  be 
consulted. 

Infection  of  the  sinuses  of  the  skull  is  very  difficult  to 
treat  by  local  measures.  Mixed  vaccines  are  recommended. 
When  these  infections  become  purulent,  however,  surgical  in- 
ters'ention  is  required. 

FISSURES    OF   THE    LIPS. 
(Rhagades  of  Commissures.) 

This  condition  is  characterized  by  a  fissured  eczema-like 
masceration  of  the  corners  of  the  mouth,  which  is  quite  pain- 
ful when  the  lips  are  parted,  or  when  fluids  come  in  contact 
with  the  affected  parts.  It  occurs  most  frequently  in  children, 
but  may  also  occur  in  adults  whose  physical  condition  is  be- 
low par.  The  angles  of  the  mouth  are  reddened  and  scale-like, 
and  the  epithelium  is  deeply  fissured.  Itching  and  burning, 
are  characteristic  symptoms.  Both  corners  of  the  mouth  are 
usually  affected  at  the  same  time. 

The  disease  seems  to  bear  some  relation  to  the  home  en- 
vironments of  those  affected,  it  being  found  most  frequently 
among  those  living  in  poor  surroundings  and  under  poor  dis- 
cipline, of  personal  hygiene.  In  adults  it  is  generally  associa- 
ted with  chronic  diseases,  and  is  very  resistant  to  treatment. 


HERPES  LABIALIS.  649 

Fissures  should  be  cauterized  with  a  solution  of  silver 
nitrate,  10  grains  to  the  ounce  (0.65  Gms.  to  30  mils),  followed 
by  the  application  of  an  ointment,  the  composition  of  which  is 
as  follows : 

IJ  Hydrarg.  oxid.  flav gr.  ss  (0.032  Gm.). 

Petrolatum  album 5j  (3.90  Gms.) . 

S. :    Apply  locally  at  bedtime. 

Zinc  ointment  may  also  be -applied  with  beneficial  effect. 
Camphor  ice  is  also  recommended.  The  general  health  of  the 
patient  should  be  given  careful  consideration  and  treatment 
instituted  according  to  the  individual  requirements. 


HERPES    LABIALIS. 
(Cold  Sores;  Fever  Blisters.) 

This  condition  is  characterized  by  the  eruption  of  vesicles 
varying  in  size  from  a  pin-head  to  that  of  a  split  pea  upon  the 
exposed  surface  of  the  lips  and  skin  adjacent  thereto.  These 
vesicles  may  be  single,  multiple,  or  confluent,  and  rest  upon 
hyperemic  bases.  Their  appearance  is  usually  preceded  by  a 
burning  or  tingling  sensation  of  the  lips,  soon  followed  by  an 
eruption  of  varying  sized  watery  blisters.  The  lips  are  dry, 
glazed,  and  reddened.  The  contents  of  the  vesicles  are  at  first 
clear,  but  soon  become  milky.  Absorption  takes  place  after 
several  days,  leaving  reddish  brown  crusts,  which  soon  fall  ofif. 
Picking  at  these  crusts,  however,  will  cause  them  to  bleed, 
leaving  denuded  painful  surfaces.  In  children  there  is  a  tend- 
ency to  pick  at  these  crustasions,  causing  irritation  and  in- 
flammation in  the  tissues  immediately  adjacent. 

Herpes  occurs  in  digestive  disorders,  constipation,  febrile 
diseases,  pneumonia,  malaria,  and  in  acute  catarrhal  affections 
of  the  nose  and  throat. 

Treatment.  It  is  very  difificult  to  abort  eruptions  of  herpes 
because  they  appear  so  rapidly.  Sweet  spirits  of  nitre  con- 
taining a  few  drops  of  tincture  of  belladonna;  or  spirits  of 
camphor  may  be  used  to  hasten  the  drying  of  the  vesicles. 
Alcohol  or  tincture  of  benzoin  is  also  recommended.  After 
the  scabs  have  formed,  they  should  be  softened  with  cold 
cream,  yellow  oxid  ointment,  or  white  vaselin. 


650  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 


FOUL    BREATH. 

A  continuously  offensive  breath  is  always  indicative  of  an 
abnormal  condition.  After  eating  certain  foods,  the  breath 
may  have  an  odor  characteristic  of  these  substances,  such  as 
occurs  after  the  ingestion  of  alcohol,  creosote,  mint,  onions, 
and  garlic.  A  disagreeable  odor  from  the  mouth  which  per- 
sists may  signify  the  presence  of  decayed  teeth,  diseased  ton- 
sils, inflammatory  disease  of  the  nose,  throat,  and  sinuses  of 
the  face,  gastro-intestinal  disorders,  chronic  constipation, 
Bright's  disease,  diabetes,  fetid  bronchitis,  gangrene  of  the 
lungs,  pulmonary  tuberculosis,  cancrum  oris,  cancer  of  the 
tongue  or  lar}'nx,  or  may  be  associated  with  chronic  wasting 
diseases.  An  odor  may  also  be  imparted  to  the  breath  follow- 
ing poisoning  by  mercury,  arsenic,  lead,  and  phosphorus. 
The  constant  use  of  bromids  and  iodids  may  also  give  a  char- 
acteristic odor  to  the  breath. 

The  treatment  of  this  condition  of  course  deals  with  the 
removal  of  the  cause.  Attention  to  the  teeth  is  very  impor- 
tant and  the  occasional  administration  of  saline  purges  is  in- 
dicated. The  mouth  should  be  washed  after  each  meal  with  a 
solution  of  peroxid  and  listerine  equal  parts,  or  with  Dobell's 
solution  or  liquor  antisepticus  alkalinus. 

GINGIVITIS. 

Inflammatory  conditions  of  the  gums  may  involve  the 
superficial  surface  or  marginal  areas  close  up  to  the  teeth  or 
may  extend  to  the  deeper  structures  as  in  alveolar  processes 
of  the  maxillary  bones. 

Retained  particles  of  putrefactive  and  decomposed  food  or 
general  systemic  diseases  may  bring  about  a  superficial  gingi- 
vitis. Irritation  from  overhanging  crowns  and  faulty  fillings 
may  also  bring  about  this  condition.  In  certain  diseases,  such 
as  tuberculosis,  syphilis,  Bright's  disease,  scurvy,  diabetes,  in 
cases  of  alcoholism,  in  advanced  grades  of  anemia,  and  some- 
times in  febrile  diseases,  the  gums  are  hyperemic,  tender,  and 
bleed  easily  on  touch.  Burns  by  chemicals,  such  as  bichlorid 
of  mercur}^  carbolic  acid,  and  other  corrosive  medications, 
may  cause  inflammatory  conditions  of  the  gum.    The  internal 


PYORRHEA  ALVEOLARIS.  651 

administration  of  mercury  and  iodids  may  also  cause  gingi- 
vitis. Various  industrial  occupations  in  lead,  phosphorus,  and 
mercury  may  affect  the  gums.  The  causative  factor  must  be 
removed.  Imperfect  and  faultily  done  work  should  be  cor- 
rected, and  industrial  pursuits  should  be  either  abandoned  or 
controlled  by  careful  medical  supervision.  Systemic  diseases 
should  be  treated  accordingly, 

A  suitable  mouth  wash  for  superficial  gingivitis  is  as  fol- 
lows: 

Sod.  bicarbonatis, 

Sod.  biboratis aa  3j   (3.90  Gms.). 

Acidi  carbolici  3ss  (1.95  Gms.). 

Glycerini  f 5j  (31  Gms.) . 

Aqua  destillata,  q.  s.  ad f3iv  (124.40  Gms.). 

M.     S. :     One  tablespoonful  (15  mils)  to  a  half-glass 

of  water  and  use  as  a  mouth-wash  every  two         » 
hours. 

PYORRHEA    ALVEOLARIS. 

This  is  an  infection  of  the  mouth  characterized  by  a  bleed- 
ing, spongy,  purulent  condition  of  the  gums  and  by  inflamma- 
tion of  the  pericemental  membrane  of  the  teeth.  This  may 
arise  from  local  disease  caused  by  infection  from  carious  teeth 
with  the  various  pathogenic  organisms — bacilli,  cocci,  or 
amebse.  Crustations  of  tartar  at  the  neck  of  the  teeth  imping- 
ing upon  the  gums  may  be  the  origin  of  this  infection,  or  it 
may  begin  in  uric  acid  deposits  at  the  roots  of  the  teeth  in  the 
case  of  certain  constitutional  diseases,  such  as  gout  and  lithic 
diatheses. 

"Two  decades  find  us  almost  exactly  where  we  were  when 
I  started  to  practice  dentistry  twenty-three  years  ago,"  says 
Price, -^  of  Cleveland,  at  the  67th  annual  session  of  the  Ameri- 
can Medical  Association,  Detroit,  June,  1916.  "We  cannot 
come  together  and  express  a  cornmon  idea  on  the  etiology  of 
pyorrhea,  and  be  noted  in  supporting  and  substantiating  it." 
This  is  the  general  opinion  expressed  by  some  of  the  most 
prominent  American  dental  authorities  to-day.  Only  recently 
a  well-known  research  worker  proclaimed  that  the  Endanieha 
bitccalis  was  the  cause  of  every  case  of  pyorrhea,  and  that  this 
•disease  was  present  among  95  per  cent,  of  the  population. 
This  staternent,  however,  has  been  disproved  many  times  by 


652  DISEASES    OF   THE   DIGESTIVE    SYSTEM. 

various  bacteriological  experiments  conducted  in  research 
laboratories.  Among  the  organisms  which  have  been  isolated 
from  the  diseased  gums  and  pyorrhea  are  the  streptococcus, 
pneumococcus,  staphylococcus,  staphylococcus  aureus,  micro- 
coccus catarrhalis,  saccharomyces,  treponema  mucosum,  in- 
fluenza bacillus,  diphtheroids,  and  endameba.  The  variety  of 
bacteria  found  indicates  that  one  or  more  causative  agents 
may  singly  or  jointly  produce  the  same  pathological  condition 
known  as  p3^orrhea.  It  appears,  however,  that  the  strepto- 
coccus is  the  principal  and  most  frequent  active  cause  of  the 
disease.  Recent  investigations  of  the  characteristics  of  the 
streptococcus  point  to  the  fact  that  this  micro-organism  has 
many  possibilities,  and  it  varies  in  virulence  according  to  the 
strain  or  famih^  group  from  which  it  is  derived,  and  according 
to  the  resisting  power  of  the  patient.  This  bacterium,  under 
varying  conditions  of  growth,  m.ay  possess  different  character- 
istics, being  capable  of  various  changes,  and  even  convertible 
into  micro-organisms  resembling  the  pneumococcus,  which 
in  turn  may  be  reconverted  into  the  streptococcus.  These, 
micro-organisms,  depending  upon  their  strain  and  character- 
istics, possess  selective  action  for  certain  parts  of  the  body, 
showing  preference  to  the  joints,  the  heart,  the  kidne^^s,  and 
other  organs.  When  recoA'ered  from  these  various  parts  of 
the  body  and  injected  into  laboraton,-  animals,  the}"  produce 
exactly  the  same  lesions  and  in,  the  same  organs  from  which 
they  are  derived.  These  specific  qualifications  of  various 
strains  of  the  same  germ  bear  an  important  relation  to  the 
treatment,  since  special  strains  of  germs  must  be  used  in  vac- 
cine therapy  depending  upon  their  selective  preference  for 
certain  parts  of  the  body. 

In  view  of  the  varied  opinions  expressed  as  to  the  cause  of 
pyorrhea,  it  is  safe  to  state  that  this  disease  is  an  infection  of 
the  gums,  occurring  most  frequently  in  persons  whose  physi- 
cal condition  is  below  par.  Rhein^  states  that  infection  is 
impossible  in  an  individual  otherwise  physically  well.  "Pyor- 
rhea alveolaris  is  the  result  of  malnutrition  plus  infection,  and 
also  most  frequenth^  plus  irritation."  Talbot°  claims  that 
deposits  on  the  roots  of  the  teeth  other  than  tartar  are  the 
detritus  of  destroyed  bone,  and  are  not  deposits  from  the 
blood  as  was  formerly  supposed.    Alany  authorities  claim  that 


PYORRHEA  y\LVEOLARIS.  653 

these  deposits  are  composed  of  uric  acid,  which  is  precipitated 
from  the  blood.  Talbot  sums  up  the  etiology  of  these  diseases, 
as  follows : 

1.  We  have  to  contend  with  the  bone  (teeth)  as  an  end 
organ  in  which  the  blood  accumulates. 

2.  Stasis  of  the  blood  cuts  off  nutrition.  ^ 

3.  Local  and  constitutional  irritation  and  chemical  changes 
of  the  blood  set  up  a  low  form  of  inflammation  and  bone 
absorption. 

4.  The  absorption  is  enhanced  because  of  the  transitory 
nature  of  the  alveolar  process. 

5.  Nerve  end  degeneration  and  arteriosclerosis  occur. 

6.  Want  of  vital  resistance  assists  absorption. 

This  disease  is  of  extreme  importance  in  that  it  may  com- 
plicate general  and  infectious  diseases,  or  that  it  may  be  the 
original  focus  for  the  dissemination  of  lesions  in  distant 
organs.  Whether  the  disease  arises  in  the  cementum  or  in  the 
peridental  membrane  means  little  to  the  average  practitioner, 
but  it  is  of  great  concern  to  him  whether  the  infection  is  a 
primary  disease  of  the  gums  or  whether  it  is  a  superadded 
infection  occurring  in  the  course  of  general  systemic  diseases. 

Diseased  conditions  of  the  gum  which  are  not  readily 
amenable  to  treatment  may  have  a  cryptic  source  of  infection 
about  the  root  of  one  or  more  teeth.  These  so-called  periapical 
abscesses  may  exist  with  few  or  no  symptoms  referable  to 
the  mouth.  There  may,  however,  be  general  symptoms  of 
toxemia,  of  physical  and  mental  depression,  of  malnutrition, 
anemia,  and  neurasthenia.  Indefinite  pains  in  the  joints  or 
definite  heart  lesions  may  have  their  origin  in  a  purulent  infec- 
tion about  the  roots  of  the  teeth.  There  is  now  a  general 
tendency  on  the  part  of  the  medical  profession  to  make  a 
routine  inspection  of  the  mouth  for  the  purpose  of  detecting 
hidden  lesions  about  the  teeth.  The  x-ray  has  been  of  invalu- 
able service  in  this  respect.  Potter^  recommends  that  a  gen- 
eral survey  of  the  denture  by  a  series  of  dental  films  is  an 
important  adjunct  to  the  examination  of  a  pyorrhea  case.  It 
is  often  a  short  cut  to  a  diagnosis,  and  is  less  disagreeable 
than  an  instrumental  examination,  but  should  supplement 
rather  than  displace  other  diagnostic  methods.  The  most 
important  findings  are  observed  in  the  region  of  the  intimate 


654  DISEASES   OF   THE    DIGESTIVE   SYSTEM. 

bony  inv^estments  of  the  roots,  and  are  obtained  only  from  the 
most  critical  rontgengrams.  Radiographs  do  not  always  show 
looseness  of  the  teeth,  which  is  quite  common  in  pyorrhea; 
and,  on  the  other  hand,  abscesses  are  noted  even  when  the 
teeth  are  intact  and  firm.  Inasmuch  as  the  teeth  may  be 
normal,  and  abscesses  treated  without  interference  with  the 
function  of  the  adjacent  teeth,  it  is  advisable  that  teeth  be 
extracted  only  after  consultation  with  the  dentist.  It  is  be- 
lieved that  heretofore  physicians  have  ordered  the  extraction 
of  teeth  indiscriminately  on  the  finding  of  periapical  abscesses. 
Bleeding  gums  is  one  of  the  first  S3"mptoms  of  pyorrhea. 
Painful  mastication,  toothache,  neuralgia,  foul-smelling  breath, 
and  digestive  disorders  are  present.  Palpation  of  the  gums 
elicits  tenderness,  Their  color  varies  from  the  bright  beefy 
red  to  a  dull  brown,  the  latter  being  characteristic  of  the 
shrunken  tissues  below  the  neck  of  the  teeth.  Ulcerations  of 
the  gum  and  the  mucous  membrane  also  may  occur. 

TREATMENT. 

The  diseased  gum,  with  festoons  hanging  down  between 
the  crowns  of  the  teeth,  should  be  cut  out  by  a  sharp  scalpel 
down  to  the  alveolar  border.  Bleeding  is  encouraged.  The 
gums  may  be  scarified  and  rubbed  with  a  soft  brush.  Tinc- 
ture of  iodin  should  be  applied  before  and  after  scarification. 
A  suitable  gum-wash  used  in  connection  with  the  brush  and 
massage  advocated  by  AVhistler,  of  Cleveland,  is  as  follows: 

Zinc  sulpho-carbolate 3j  (3.90  Gms.). 

Alcohol f3j   (31  Gms.). 

Aqua  dist fSiJ   (62  Gms.) . 

01.  mentha.  pip m  viij  (0.50  mils) . 

M.    S. :    Use  as  a  gum-wash. 

In  looking  over  the  recent  literature  on  the  treatment  of 
pyorrhea,  it  is  surprising  to  learn  that  ver\-  little  is  now  said 
regarding  the  use  of  emetin  hydrochlorid  and  ipecac,  which 
onh'-  lately  gained  much  popularity  among  the  medical  pro- 
fession. Since  these  drugs  are  believed  to  be  specific  in  com- 
bating the  growth  of  the  endameba,  and  since  the  micro- 
organism, just  named  seems  to  be  a  complicating  factor  rather 
than  the  original  cause  of  the  disease,  these  drugs  no  longer 
possess  an  important  part  in  the  treatment. 


CATARRHAL  STOMATITIS.     '  655 

General  measures  of  treatment  are  indicated  in  pyorrhea. 
Saline  purgatives  of  Epsom  salt,  citrate  of  magnesia,  Rochelle 
salt,  and  other  measures  may  be  used.  The  salt  action  of 
these  purgatives  tends  to  relieve  the  blood  system  of  its  toxic 
products,  and  clears  the  intestinal  tract  of  putrefactive 
material  which  would  otherwise  exaggerate  the  constitutional 
symptoms  of  pyorrhea.  The  internal  administration  of  salicy- 
lates is  also  of  great  value  in  combating  the  micro-organisms 
and  their  products,  absorbed  from  focal  infections  in  the 
mouth,  and  distributed  through  the  blood  vascular  system. 
Perversion  of  taste,  which  very  often  accompanies  pyorrhea, 
may  be  overcome  by  using  a  mouth-wash  of  Dobell's  solution, 
or  a  solution  of  potassium  permanganate  (1:500).  Candy 
lozenges  containing  menthol,  licorice,  or  peppermint  are 
recommended  when  there  is  much  fetor  of  the  breath  accom- 
panying the  disease. 

General  tonics,  such  as  iron,  nux  vomica,  and  bichlorid  of 
mercury,  should  be  administered. 


CATARRHAL    STOMATITIS. 

Catarrhal  stomatitis  is  a  general  inflammatory  condition  of 
the  mucous  membrane  of  the  mouth  attended  with  an  in- 
creased secretion  of  saliva.  It  may  arise  from  decomposing 
food  particles,  carious  teeth,  and  from  general  uncleanliness 
of  the  mouth.  The  constant  chewing  of  tobacco,  indulgence 
in  strong  alcoholic  liquors,  ingestion  of  highly  spiced  foods, 
and  various  drugs  (iodids,  arsenic,  and  bromids)  may  be  the 
exciting  causes.  Constitutional  diseases,  infectious  fevers,  and 
certain  occupations  among  chemicals,  may  be  responsible  for 
catarrhal  inflammation  of  the  mouth.  Gastro-intestinal  dis- 
orders, organic  diseases,  pregnancy,  and  lactation  also  may 
predispose  to  this  disease'. 

It  occurs  not  only  in  adults,  but  also  frequently  among 
children.  Unhygienic  surroundings,  poor  feeding,  malnutri- 
tion, and  gastro-intestinal  disorders  in  the  infant  may  act  as 
exciting  causes.  The  so-called  pacifiers  for  the  young  infant 
may  readily  carry  into  the  mouth  infectious  bacteria,  result- 
ing in  ulceration   and   catarrhal   inflammation.     Throughout 


656  DISEASES    OF    THE   DIGESTIVE    SYSTEM. 

the  mouth  may  be  found  inflammatory  glazed  areas  of  mucous 
membrane,  and  here  and  there  white  patches. 

The  treatment  is  confined  to  general  measures  of  cleanli- 
ness. In  children  the  mouth  can  be  cleansed  by  sweeping  it 
with  a  finger  or  with  a  gauze-covered  finger  moistened  with 
boric  acid  solution.  The  infant's  mouth  should  be  Avashed  in 
this  way  before  and  after  each  feeding.  The  mother's  nipple 
should  also  be  washed  with  boric  acid  solution  before  and 
after  each  feeding.  If  the  child  uses  the  bottle,  the  nipple 
should  be  thoroughly  boiled.  In  adults  a  suitable  wash 
should  be  used  several  times  during  the  day,  and  the  teeth 
carefull}^  brushed.  Ulcerated  areas  may  be  treated  by  the 
application  of  a  10  per  cent,  solution  of  silver  nitrate.  Among 
the  mouth-washes  recommended  are  Dobell's  solution,  liquor 
antisepticus  alkalinus,  potassium  •  permanganate  (1:1000), 
and  peroxid  and  glycerin  (1:4)  diluted  with  equal  parts  of 
water. 

APHTHOUS    STOMATITIS. 
(Herpetic,  Vesicular,  Follicular.) 

This  disease  is  manifested  by  a  A'esicular  eruption  on  the 
mucous  membrane  of  the  mouth,  cheek,  tongue,  or  lips. 
These  vesicles  are  the  size  of  a  pinhead,  or  slighth-  larger,  and 
readily  ulcerated,  exhibiting  a  necrotic  yellowish  white  base 
surrounded  by  a  red  areola.  It  occurs  chiefly  among  children 
between  the  ages  of  six  months  and  the  end  of  the  first  den- 
tition. Adults  also  may  be  affected.  It  is  believed  that  the 
disease  is  caused  by  some  toxic  product  affecting  the  nerves 
of  the  mouth,  resulting  in  herpetic  eruptions.  Various  bac- 
teria have  been  isolated,  but  none  other  than  those  found 
normally  in  the  secretions  of  the  mouth.  Among  the  predis- 
posing causes  are  malnutrition,  tuberculosis,  diarrhea  and 
enteritis,  infectious  fevers,  and  dentition.  Lack  of  cleanliness, 
the  use  of  stale  and  unclean  milk,  and  the  indiscriminate  use 
of  baby  comforters  are  among  the  exciting  factors  which 
favor  this  disease.  In  adults  it  results  from  inattention  to 
personal  hygiene ;  it  may  be  caused  by  carious  teeth,  or  by 
the  ingestion  of  highly  spiced  foods,  or  it  may  occur  during 
the  course  of  gastro-intestinal  disorders.     It  may  also  occur 


APHTHOUS  STOMATITIS.  657 

during"  the  puerperium  and  lactation.  When  the  vesicles 
break  down  and  ulcerate,  they  become  very  painful  and  ten- 
der, especially  during  mastication,  when  the  food  comes  in 
contact  with  the  denuded  areas.  The  vesicles  are  usually 
found  inside  the  lower  lip  near  the  frenum  on  the  mucous 
membrane  of  the  cheeks  near  the  back  teeth,  and  along  the 
edges  of  the  tongue.  Increased  salivation  usually  accom- 
panies the  eruption.  In  children  it  may  be  associated  with  a 
slight  rise  of  temperature,  or  it  may  precede  an  attack  of 
gastro-enteritis. 

Follicular  stomatitis  occurs  during  the  course  of  child- 
hood diseases — pneumonia  or  typhoid  fever.  The  ulcers  may 
coalesce,  forming  large  necrotic  areas,  which  are  very  painful. 
The  disease  usually  runs  a  short  course. 

TREATMENT. 

In  children  every  effort  should  be  made  to  keep  the  mouth 
clean  by  swabbing-  it  out  thoroughly  with  a  gauze-tipped 
finger  moistened  with  boric  acid  solution,  or  with  sodium 
bicarbonate,  10  grains  to  the  ounce  (0.65  Gm.  to  30  mils)  of 
water.  Painful  ulcers  should  be  touched  with  a  2  per  cent, 
solution  of  cocain  before  feeding,  and  should  be  cauterized  by 
thcapplication  of  a  10  per  cent,  solution  of  silver  nitrate  on  a 
cotton-tipped  applicator,  or  a  saturated  solution  of  iodoform 
in  ether.  The  following  internal  medication  is  recommended 
by  Anders  -J 

Potassii  chloratis gr.  xxiv  (1.55  Gms.). 

Tr.  of  myrrhae gtt.  x  (0.60  mils) . 

Syr.  acacise  f5ij  (62  Gms.) . 

Aqua  dest.,  q.  s.  ad fjiij  (93  Gms.). 

M.    S. :    fSj  (3.75  mils)  every  three  hours  for  a  child 
3  years  of  age. 

A  word  of  caution  may  be  said  against  the  use  of  the  paci- 
fier, playtoys,  and  rattles,  which  are  frequently  taken  into  the 
mouth  by  the  infant.  We  have  too  often  seen  the  mother  pick 
up  the  pacifier  or  rattle  from  the  floor,  wipe  it  on  the  apron, 
and  hand  it  to  the  child.  Infection  may  be  readily  carried  into 
the  mouth  by  these  toys.  The  pacifier  should  be  strictly 
forbidden. 

42 


658  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 


BEDNAR'S    APHTHA. 

This  is  the  name  applied  to  an  ulcerative  condition  of  the 
soft  palate  and  roof  of  the  mouth  among  infants  soon  after 
birth,  and  is  said  to  be  caused  by  abrasions  of  the  mucous 
membrane  occasioned  by  the  rough  swabbing  of  the  mouth 
by  the  nurse  or  doctor,  or  as  the  result  of  traumatism  caused 
by  friction  of  a  long  rubber  nipple. 

This  condition  is  treated  by  swabbing  the  mouth  with  a 
solution  of  boric  acid,  and  in  more  severe  cases  by  the  applica- 
tion of  a  10  per  cent,  silver  nitrate  solution. 

THRUSH. 
(Stomatitis  Hyphomycetica ;  Parasitic  or  Mycotic  Stomatitis.) 

Infection  of  the  mucous  membrane  of  the  mouth  by  a 
mycotic  moldy  growth  resembling  curds  of  milk,  which  are 
difficult  to  remove,  may  occur  among  infants,  children,  and 
the  aged.  This  is  known  as  thrush.  It  afifects  the  lips, 
tongue,  cheeks,  soft  palate,  and  occasionally  the  pharymx, 
esophagus,  and  upper  respiratory  passages.  This  mycelial 
or  moldy  growth  is  caused  by  one  of  the  higher  forms  of 
bacteria  known  as  the  endomyces  albicans,  and  produces  a 
lesion  in  flake-like  patches  superimposed  upon  an  already  in- 
flamed mucous  membrane.  The  endomyces  grows  best  in  an 
acid  medium.  This  fact  is  of  therapeutic  importance  in  that 
alkaline  lotions  are  required  to  hinder  its  development.  The 
disease  occurs  among  nursing  infants  affected  by  gastro- 
intestinal disorders,  under-nourishment,  tuberculosis,  and 
other  wasting  diseases.  Infection  may  be  introduced  into  the 
mouth  by  unclean  nipples,  by  table  utensils,  or  by  pacifiers 
and  other  trinkets.  Older  children  may  become  infected  by 
placing  foreign  bodies  in  the  mouth.  Among  the  aged  the 
disease  occurs  in  the  course  of  cachetic  diseases. 

TREATMENT. 

The  mouth  of  the  infant  should  always  be  kept  clean  by 
cleansing  it  after  each  feeding  with  a  gauze-tipped  finger 
moistened  in  boric  acid  solution.    The  mother's  breast  should 


ULCERATIVE  STOMy\TJTlS.  659 

be  treated  likewise  before  and  after  each  feeding.  Bottle-fed 
babies  should  receive  generous  care  in  the  preparation  of 
their  feedings,  and  attention  paid  to  the  cleanliness  of  the 
nipples.  The  milk  should  be  fresh,  and  free  from  contamina- 
tion. Children  should  be  taught  not  to  place  toys  and  other 
foreign  bodies  in  their  mouths,  and  parents  should  prohibit 
the  use  of  pacifiers.  In  adults,  and  especially  among  the 
aged,  the  routine  use  of  one  of  the  common  mouth-washes  is 
advocated. 

When  the  disease  has  developed,  the  afifected  parts  should 
be  treated  with  a  solution  of  sodium  bicarbonate  or  sodium 
biborate,  10  grains  to  the  ounce  (0.65  Gm.  to  30  mils),  on 
gauze-tipped  finger  or  on  a  cotton-tipped  applicator.  Adults 
may  use  to  advantage  a  mouth  gargle  of  liquor  antisepticus 
alkalinus,  sodium  bicarbonate,  or  sodium  biborate,  10  grains  to 
the  ounce  (0.65  Gm.  to  30  mils).  The  mycotic  growth 
should  not  be  removed,  since  it  usually  carries  with  it  the 
mucous  membrane,  leaving  ulcerated  areas.  Should  ulcera- 
tions result,  however,  they  should  be  treated  by  the  applica- 
tion of  silver  nitrate,  10  grains  to  the  ounce  (0.65  Gm.  to 
3  mils). 

ULCERATIVE    STOMATITIS. 

(Vincent's  Angina;  Fetid  Stomatitis;  Putrid  Sore  Throat.) 

This  is  an  acute  inflammatory  and  ulcerative  infection 
of  the  gums,  and  later  may  extend  to  the  maxillary  bones.  It 
occurs  among  children  from  the  age  of  three  to  puberty,  and 
also  may  affect  adults.  Unhygienic  surroundings,  together 
with  poor  feeding,  under-riourishment  and  undermined  physi- 
cal health  are  predisposing  factors.  It  may  develop  during 
the  course  of  febrile  diseases,  measles,  scarlet  fever,  typhoid, 
and  other  infections,  or  it  may  result  from  the  invasion  of  bac- 
teria into  tissues  whose  resistance  is  lowered  by  chemical  or 
mechanical  irritation.  Mercury,  phosphorus,  arsenic,  iodids, 
and  bromids  may  produce  ulcerative  stomatitis.  It  may  occur 
in  the  course  of  syphilis,  "tuberculosis,  cancer,  and  other  wast- 
ing diseases. 

The  gums  of  the  lower  jaw  become  painful,  reddened  and 
swollen,  and  soon  ulcerate,  with  dirty  white  necrotic  areas 


660  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

surrounded  by  bleeding,  spongy  tissue.  If  untreated,  these 
ulcerations  extend  rapidly  to  other  parts  of  the  mouth,  affect- 
ing the  gums  on  the  labial  and  lingual  surfaces.  The  slough- 
ing becomes  discolored,  and  there  is  distinct  fetor  of  the  breath. 
There  is  an  increased  flow  of  saliva,  which  in  cases  of  debility 
overflows,  running  down  the  corners  of  the  mouth,  producing 
redness  and  excoriations  upon  the  skin  of  the  lower  jaw.  In 
many  instances  the  inflammatory  condition  actually  may  cause 
a  periostitis  of  the  maxillary  bones,  attended  with  pain  and 
swelling  of  the  sub-maxillary  glands.  The  disease  may  be 
associated  with  fever,  gastro-intestinal  disorders,  and  extreme 
prostration.  It  may  progress  rapidly,  causing  extensive 
ulcerations  of  the  mouth  within  from  three  to  five  days.  Jn 
institutions  this  affection  may  become  epidemic  through  the 
use  of  common  eating  utensils,  cups,  glasses,  and  towels. 

TREATMENT. 

The  treatment  calls  for  the  adoption  of  sanitary  measures 
in  institutions  where  the  disease  occurs.  The  common  use  of 
eating  utensils,  glasses,  and  drinking-cups  should  be  pro- 
hibited. Housing  conditions  should  be  improved.  Patients 
should  be  encouraged  to  be  out-doors  in  favorable  weather.  A 
mixed  and  wholesome  diet  should  be  given  the  inmates  of  in- 
stitutions to  avoid  malnutrition,  which  in  turn  predisposes  to 
infections.  Ulcerative  stomatitis  should  be  treated  by  the  use 
of  3.  mouth-wash  composed  of  10  grains  to  the  ounce  (0.65 
Gm.  to  30  mils)  solutions  of  sodium  bicarbonate,  sodium 
biborate,  potassium  chlorate,  alum,  or  tannic  acid,  or  potas- 
sium permanganate  (1 :  500)  may  ser^'e  best. 

The  ulcerated  area  should  be  treated  with  peroxid  of  hy- 
drogen, followed  by  the  application  of  tincture  of  iodin  or  10 
per  cent,  solution  of  silver  nitrate.  Children  may  be  given 
potassium  chlorate  internally,  as  described  under  Aphthous 
Stomatitis.  (See  p.  657.)  This  drug  may  also  be  given  to 
adults,  but  is  contraindicated  in  cases  associated  with  nephri- 
tis. Under  constant  treatment  the  disease  may  be  abated  in 
from  four  days  to  one  week.  In  cases  of  longer  standing,  the 
deeper  structures  become  affected,  resulting  in  alveolar  necro- 
sis.    In  such  cases  the  necrotic  areas  should  be  curetted  and 


GANGRENOUS  STOMATITIS.  661 

dusted  with  powdered  iodoform  once  daily.     The  teeth,  how- 
ever, should  not  be  removed  unless  carious. 

The  general  constitutional  condition  of  the  patient  should 
be  improved  by  dietary  measures — fresh  fruits,  vegetables, 
fresh  milk  of  good  quality — and  by  the  administration  of 
elixir  ferri,  quininse  et  strychninse  phosphatum.  In  cases  of 
scorbutic  history,  it  is  advisable  to  administer  codliver  oil, 
orange  juice,  lemon  juice,  and  to  give  a  mixed  diet. 

GANGRENOUS    STOMATITIS. 
(Noma;  Cancrum  Oris.) 

This  is  a  gangrenous  inflammation  of  the  cheek  and  ad- 
jacent parts  of  the  mouth,  occurring  chiefly  in  young  children 
living  under  extremely  unhygienic  conditions,  or  following 
the  usual  childhood  diseases  and  intestinal  disorders.  It  may 
be  associated  with  syphilis,  scurvy,  typhoid  fever,  or  small- 
pox.   It  is  a  rare  disease,  and  is  quite  fatal. 

Various  pathogenic  micro-organisms  have  been  found  in 
the  tissues,  among  which  are  the  Klebs-Lofifler  bacillus,  diph- 
theroid organisms,  and  spirochetes.  The  disease  begins  in  the 
mucous  membrane  of  the  cheek,  near  the  corner  of  the  mouth, 
as  an  ulcer,  spreading  rapidly  to  adjacent  tissues,  and  a  nodu- 
lar sensitive  growth  may  be  felt  between  the  palpating 
fingers.  The  skin  of  the  cheek  becomes  reddened  and  brawny 
in  color,  and  is  greatly  swollen.  The  entire  thickness  of  the 
cheek  then  becomes  black  and  gangrenous,  often  sloughing 
away  so  as  to  expose  the  interior  of  the  mouth.  These  changes 
may  take  place  in  from  twenty-four  hours  to  three  or  four 
days.  Shreds  of  tissue  discharge  from  the  gangrenous  open- 
ing in  the  mouth,  and  there  is  a  distinct  foul  odor  in  the  dis- 
eased area.  The  g-angrene  may  extend  to  the  adjacent  tissues, 
afl^ecting  the  gums,  the  jaw,  and  the  entire  side  of  the  face. 
It  is  not  often  that  the  opposite  side  is  afifected.  The  disease 
is  attended  with  fever,  ranging  from  104°  to  105°  F.  (40°  to 
40.4°  C),  and  the  physical  condition  of  the  patient  rapidly 
wanes.  The  disease  is  fatal  in  from  75  to  80  per  cent,  of  the 
cases.  If  recovery  takes  place,  it  is  accompanied  by  marked 
disfigurement. 


662  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 


TREATMENT. 

Ever}'  form  of  stomatitis  occurring  in  children  should  re- 
ceive immediate  and  constant  medical  attention.  Hygienic 
conditions  in  the  home  demand  careful  attention,  and  the 
food  should  be  carefully  selected,  and  of  wholesome,  nourish- 
ing quality.  Ulcers  about  the  gums  and  cheeks  are  to  be 
immediately  cauterized  with  silver  nitrate,  and  the  mouth 
kept  in  a  clean  condition.  Suspicion  of  gangrene  calls  for 
early  and  wide  fulguration  of  the  affected  parts,  advancing  far 
into  the  healthy  tissue.  Cultures  should  be  taken  from  the  dis- 
eased parts.  Diphtheria  infection  calls  for  the  earh*  admini- 
stration of  diphtheria  antitoxin  in  doses  of  from  500  to  1000 
units,  and  repeated  as  the  individual  case  may  require.  If  the 
disease  has  progressed,  and  extensive  gangrene  is  present,  the 
diseased  area  should  be  resected  by  the  thermocautery  and 
scalpel.  The  parts  are  dressed  with  a  solution  of  potassium 
permanganate  (1 :  500^.  or  with  the  Carrel-Dakin  solution. 
The  mouth  must  be  kept  clean  by  spraying  with  liquor  anti- 
septicus  alkalinus.  General  stimulants  are  indicated  to  build 
up  the  vitality  of  the  patient. 

MERCURIAL    STOMATITIS. 

This  occurs  among  workers  in  mercury  (barometer  makers, 
chemists,  and  others  who  directly  handle  this  metal  in  the 
arts),  and  among  persons  under  medication  with  this  drug. 
The  disease  usually  is  associated  with  carious  teeth,  diseased 
gums,  and  foul,  unhygienic  condition  of  the  mouth,  and  is 
found  among  those  workers  whose  physical  condition  is  below 
par.  The  gums  are  red,  swollen,  and  tender,  and  there  is  in- 
creased salivation.  There  is  a  metallic  taste  in  the  mouth  and 
the  breath  is  fetid.  Digestive  disorders  usually  are  associated, 
as  well  as  physical  and  mental  depression. 

TREATMENT. 

The  treatment  calls  for  removal  from  the  place  of  employ- 
ment, or  for  the  withdrawal  of  internal  medication.  ]\Iercury 
must  largely  be  eliminated  through  the  bowels,  so  that  saline 
cathartics  are  therefore  indicated,  such  as  Epsom  salt,  Glau- 


CARRIERS.  663 

ber's  salt,  and  effervescing-  citrate  of  magnesia.  Hot  baths 
also  may  assist  elimination  through  the  skin.  In  cases  of 
marked  salivation,  tincture  of  belladonna  is  indicated,  8  to 
10  minims  (0.50  to  0.60  mil),  three  times  a  day.  A  mouth- 
wash of  potassium  chlorate,  10  grains  to  the  ounce  (0.65  Gm. 
to  30  mils),  or  of  the  same  strength  of  sodium  bicarbonate 
may  be  of  great  value.  In  adults,  potassium  chlorate  may  be 
administered  internally,  2  grains,  every  three  hours.  Persons 
working  in  industries  where  mercury  is  used  should  have  their 
teeth  constantly  attended  to,  and  should  use  an  antiseptic 
mouth-wash  as  a  routine  preventive  measure.  Persons,  under 
mercurial  medication  should  be  cautioned  about  attention  to 
the  teeth  and  to  the  gums. 

CARRIERS. 

Persons  who  harbor  the  germs  of  infectious  disease  in 
secretions  of  the  nose  and  mouth  or  intestinal  tract,  and  are 
not  themselves  affected  by  the  presence  of  these  micro-organ- 
isms, are  termed  carriers.  The  streptococcus,  staphylococcus, 
diphtheria  bacillus,  pneumococcus,  bacillus  of  Bordet  and 
Gengou,  influenza  bacillus,  tuberculosis  bacillus,  diplococcus 
intercellularis  meningitidis,  and  the  globoid  bodies  of  infan- 
tile paralysis  have  been  reported  to  exist  in  the  secretions 
of  the  nose  and  throat  of  persons  apparently  in  normal  physi- 
cal health.  Such  persons  may  innocently  transmit  these  micro- 
organisms to  others  through  the  act  of  sneezing,  coughing, 
spitting,  or  by  the  use  of  common  drinking  cups,  glasses,  eat- 
ing utensils,  and  towels.  When  these  bacteria  are  inhaled  and 
find  fertile  soil  for  development  in  persons  whose  vital  resist- 
ance is  below  par,  clinical  manifestations  of  their  respective 
diseases  develop.  The  carrier  problem  is  a  very  difficult  one 
to  handle.  Isolation  of  carriers  from  a  public  health  point  of 
view  seems  advisable  and  practicable  in  the  presence  of  epi- 
demics and  endemics.  It  is  difficult,  and  often  impossible,  to 
detect  all  carriers,  inasmuch  as  it  would  take  a  numerous  force 
of  medical  inspectors  to  survey  and  to  examine  a  large  pro- 
portion of  the  population  when  epidemic  diseases  prevail. 

During  the  epidemic  of  poliomyelitis  in  New  York  City, 
Newark,  and  Philadelphia,  in  1916,  it  was  believed  that  the 


664  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

carrier  was  largely  responsible  for  the  widespread  distribution 
of  this  infection.  During  the  epidemic  of  pneumonia  and  dis- 
eases of  the  respiratory  tract  in  the  northeast  section  of  the 
United  States,  principally  about  New  York  and  Philadelphia, 
during  the  winters  of  1915,  1916,  and  1917,  it  Avas  also  believed 
that  the  carrier  was  to  be  blamed  for  the  great  morbidity 
reported  in  these  localities.  Investigation  among  school  chil- 
dren indicates  that  approximately  1  per  cent,  are  carriers  of 
diphtheria.  This  conclusion  is  based  upon  systematic  inspec- 
tion and  culture  of  the  throats  of  all  children. 

TREATMENT. 

The  prevalence  of  pneumonia  in  the  various  training 
camps  of  the  National  Army  has  caused  the  Federal  officials 
to  make  an  intensive  stud}'  of  the  carrier  problem.  It  is  be- 
lieved that  the  streptococcus,  which  often  is  found  normally 
in  the  secretions  of  healthy  soldiers,  may  during  the  course  of 
an  attack  of  measles  invade  the  pulmonary  tissues  and  bring 
about  a  secondar}^  pneumonia.  The  medical  authorities  are, 
therefore,  seriousl}^  considering  the  prophylactic  inoculation 
of  every  recruit  with  an  antipneumococcus  or  an  antistrepto- 
coccus  serum  in  order  thus  to  produce  immunity  against  pul- 
monary infection  with  these  micro-organisms. 

It  is  essential  that  housing  conditions  of  both  the  militar}^ 
and  civil  population  be  carefully  super^^ised  during  an  out- 
break of  epidemic  disease,  especially  in  the  case  of  pneumonia. 
The  barracks  should  be  constructed  so  as  to  allow  free  venti- 
lation and  the  constant  circulation  of  fresh  air.  Where  people 
must  be  quartered  in  large  numbers,  and  where  space  is 
limited,  constant  ventilation  is  absolutely  essential.  Among 
the  civil  population  the  street  cars  should  be  thoroughly  ven- 
tilated at  all  times,  irrespective  of  the  type  of  weather,  and 
limited  by  the  comfort  and  needs  of  the  riding  public.  Edu- 
cational propag'anda  along  the  lines  of  careless  expectoration 
on  the  sidewalks  and  in  public  places  is  of  great  importance. 
The  public  should  be  encouraged  to  use  the  handkerchief  dur- 
ing the  act  of  coughing  and  sneezing,  and  should  be  taught 
the  advantages  of  sleeping  in  well  ventilated  bedrooms. 

Every  health  department  should  make  efforts  to  control 
carriers  by  a  system  of  inspection  and  quarantine.     The  best 


EPIDEMIC  SORE  THRUy\T.  665 

results  can  be  obtained  in  the  case  of  typhoid  and  diphtheria 
carriers.  In  the  case  of  the  former,  all  food  handlers  should 
be  licensed  by  the  health  department,  and  required  to  undergo 
a  medical  examination  for  the  purpose  of  detecting"  typhoid 
in  the  stools.  New  York  City  has  been  very  successful  in 
(detecting  many  carriers  of  disease  in  this  way,  and  in  pre- 
venting epidemics  of  typhoid  by  forbidding  such  persons  to 
be  employed  or  to  carry  on  business  in  places  where  foods 
are  handled  or  sold.  In  the  case  of  diphtheria,  all  contacts 
should  be  isolated  and  the  throats  cultured,  and  all  those 
giving  positive  results  should  be  quarantined,  and  given  such 
treatment  as  would  be  indicated  in  the  general  infections  of 
the  mouth. 

The  usual  mouth-washes,  as  indicated  in  previous  para- 
graphs, should  be  used  for  the  treatment  of  carriers  where  the  • 
infection  lies  in  the  nose  and  throat.  In  the  case  of  typhoid, 
however,  persons  should  be  instructed  regarding  the  disin- 
fection of  the  stool,  careful  cleansing  of  the  hands,  and  to 
refrain  from  contact  with  foodstuffs  intended  for  use  by  others. 
Internal  medication  to  destroy  the  typhoid  bacillus  in  such 
cases  has  not  been  very  successful.  During  serious  epidemics 
of  diphtheria  and  cerebrospinal  meningitis,  carriers  should  be 
isolated  until  negative  cultures  are  derived  from  the  nose  and 
throat. 

EPIDEMIC    SORE    THROAT. 

Epidemics  of  sore  throat  have  been  reported  from  various 
communities,  affecting  both  children  and  adults,  and  traced  to 
infection  of  the  milk  from  the  udder  of  the  cow.  The  strep- 
tococcus has  been  pointed  out  as  the  causative  agent.  The 
symptoms  are  those  of  a  sore  throat,  enlarged  tonsils,  angina, 
high  fever,  and  extreme  prostration.  Household  epidemics  of 
sore  throat  call  for  immediate  investigation  of  the  milk  supply. 
A  thorough  and  effective  system  of  pasteurization  would,  of 
course,  obviate  any  such  spread  of  disease. 

The  treatment  of  the  disease  is  the  same  as  in  any  other 
infection  of  the  throat.  Local  applications  of  20  per  cent, 
solution  of  argyrol,  or  10  per  cent,  solution  of  silver  nitrate, 
are  recommended.  Internally,  a  course  of  calomel  followed 
by  Epsom  salts  is  effective  in  reducing  the  state  of  toxemia. 


666  DISEASES    OF    THE   DIGESTIVE    SYSTEM. 

while  a  prescription  calling  for  quinin  2  grains  (Gm.  0.130), 
and  strychnin  %o  grain  (Gm.  0.00216),  three  times  a  day,  will 
directly  combat  the  infection.  A  mouth-wash  of  liquor  anti- 
septicus  alkalinus  is  also  valuable.  If  the  throat  is  very  pain- 
ful, the  patient  may  be  given  pieces  of  ice  to  hold  in  the 
mouth,  and  drinks  of  orange  juice  or  lemonade  with  shaved 
ice  are  very  soothing. 


SYPHILITIC    AFFECTIONS    OF   THE    MOUTH. 

The  secondary  stage  of  syphilis  produces  lesions  of  the 
mucous  membrane  of  the  mouth  which  are  characterized  by 
whitish  or  grayish  patches  on  the  lips,  hard  and  soft  palate, 
and  tonsils,  surrounded  by  inflammatory  bases.  Prirnary 
lesions  may  also  occur  in  the  mouth  of  the  adult,  most  fre- 
quently on  the  lips,  hard  or  soft  palate,  or  on  the  tonsils. 
Nursing  infants  may  also  present  primary  lesions  in  any  part 
of  the  mouth.  The  third  stage  or  gumma  formation  is  usually 
found  on  the  hard  or  soft  palate,  the  latter  ofttimes  being  des- 
troyed by  degenepative  processes,  which  result  in  regurgita- 
tion of  fluids  through  the  nose.  The  tongue  also  may  become 
affected  by  gummatous  degeneration  with  more  or  less 
hardening  of  the  tissues. 

TREATMENT. 

The  treatment  is  a  part  of  the  general  medication  for  the 
systemic  infection  of  syphilis.  Salvarsan,  neosalvarsan,  and 
the  American  products  arseno-benzol  and  arsphenamin,  licen- 
sed by  the  United  States  Government,  are  the  preparations 
most  valuable  in  the  treatment,  either  in  the  secondary  or 
tertiary  stage.  (See  Vol.  i,  p.  80.)  lodids  and  mercury  are 
indicated.  Locally,  the  usual  mouth-washes,  such  as  Dobell's 
solution,  liquor  antisepticus  alkalinus  and  equal  parts  of  per- 
oxid  and  listerine,  may  be  used  in  the  treatment  of  the  mucous 
patches.  Silver  nitrate  (10  per  cent.)  may  also  be  applied 
daily  to  the  ulcerated  areas. 

Patients  should  be  instructed  regarding  the  use  of  common 
eating  utensils,  handkerchiefs,  towels,  and  drinking  cups.  In 
a  number  of  States  persons  affected  with  active  syphilis  can- 


GONORRHEA  OF  THE  MOUTH.  667 

not  be  employed  in  public  eating  places,  restaurants,  dining- 
cars,  hotels,  saloons,  lunch  counters,  and  other  places  where 
foods  are  sold.  In  many  cities  milk  dealers  and  produce  mer- 
chants are  routinely  inspected,  and  forbidden  to  carry  on  their 
business  if  they  themselves  are  infected  and  come  in  contact 
with  the  merchandise.  It  is  very  important  that  persons  in 
institutions,  hospitals,  and  asylums,  and  in  military  camps  be 
isolated  when  suffering  from  secondary  lesions  of  syphilis. 
Extensive  transmission  of  the  disease  has  been  known  to  occur 
where  there  has  been  laxity  in  these  institutions  in  causing 
isolation  of  such  patients.  The  so-called  sanitary  bubbling 
fountains  have  been  condemned  because  active  micro-organ- 
isms of  syphilis  have  been  found  on  the  mouth  pieces,  in  spite 
of  the  constant  flushing  with  water.  For  the  same  reason 
common  cigar-cutters  have  been  condemned.  The  physician 
should  in  a  sense  act  as  a  health  officer  and  instruct  his 
patients  accordingly. 

GONORRHEA    OF   THE    MOUTH. 

Gonorrhea  of  the  mouth  may  occur  in  infants  from  two  to 
twelve  days  after  birth.  Infection  in  the  parturient  canal  may 
be  the  exciting  factor,  although  infection  is  known  to  occur 
through  carelessness  on  the  part  of  the  nurse  or  mother  in 
cleansing  the  mouth  of  the  child.  In  adults  the  infection  is 
characterized  by  marked  inflammation  and  swelling  of  the 
soft  parts. 

Silver  nitrate,  10  grains  to  the  ounce  (0.65  Gm.  to  30  mils), 
should  be  applied  to  the  ulcerated  and  inflamed  surfaces  twice 
daily.  Glycerite  of  tannin  (50  per  cent.)  may  also  be  used  for 
this  purpose.  The  usual  mouth-washes  already  recommended 
under  this  section  are  indicated,  such  as  peroxid  and  liquor 
antisepticus  alkalinus. 


668  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

DISEASES  OF  THE  TONGUE. 

ACUTE    GLOSSITIS. 

Inflammation  of  the  tong'ue,  either  acute  or  chronic,  may 
exist  alonei  or  as  a  part  of  a  general  mouth  infection.  Acute 
glossitis  affecting  only  the  superficial  structures  of  the  tongue 
generally  accompanies  the  acute  stages  of  tonsillitis,  stoma- 
titis, phar>-ngitis,  digestive  disorders,  and  various  systemic 
-^:  'diseases,  or  it  is  directly  the  result  of  traumatism. 

The  tongue  is  slig'htly  swollen,  the  epithelium  is  thickened 
and  reddened,  and  the  papillse  stand  out  prominently.  There 
is  a  sense  of  thickness  of  the  tongue,  dryness,  and  sometimes 
pain  on  mastication  or  SAvallowing. 

When  the  deeper  structures  of  the  tongue  are  affected, 
the  condition  may  be  attributed  to  marked  traumatism  from 
a  bite  or  from  irritation  of  a  decayed  or  displaced  tooth,  or 
from  burns  of  caustic  drugs,  poisons,  and  chemicals.  Tuber- 
culosis, syphilis,  scarlet  fever,  typhoid  fever,  smallpox,  and 
er3'sipelas  ma}-  be  attended  with  acute  glossitis.  The  infiam- 
mator}"  process  may  be  so  great  as  to  cause  the  tongue  to 
protrude  between  the  lips.  The  face  seems  full,  and  the  gen- 
eral appearance  of  the  patient  may  be  changed.  Deglutition 
and  respiration  may  be  very  difficult;  the  temperature  is 
elevated,  and  there  is  a  feeling  of  weakness  and  discomfort. 
If  the  inflammatory  process  goes  on  to  suppuration,  the 
temperature  and  general  symptoms  are  intensified.  The  sub- 
maxillary and  sublingual  glands  become  enlarged,  and  the 
chin  appears  double.  The  prognosis  is  usually  favorable. 
When,  however,  the  infection  is  rapid,  the  disease  may  extend 
to  the  glottis,  with  fatal  consequences.  If  gangrene  super- 
venes, the  condition  becomes  intensely  grave. 

TREATMENT. 

In  the  mild  catarrhal  type,  an  alkaline  mouth-wash  used 
every  two  hours  is  beneficial.  Liquor  antisepticus  alkalinus  is 
as  good  as  any.  Sodium  biborate  and  sodium  chlorid,  5  grains 
each  to  the  ounce  (0.32  Gm.  to  30  mils)  of  water,  make  an 
efficient  lotion.  The  burning  sensation  of  the  tongue  may  be 
relieved  bv  cracked  ice. 


CHRONIC  GLOSSITIS.  669 

When  the  deeper  structures  are  implicated,  the  patient 
should  be  thoroughly  purged  with  Epsom  salts,  citrate  of 
magnesia,  or  gray  powder,  or  by  the  use  of  compound  cathar- 
tic pills.  An  ice-cap  about  the  neck  gives  great  relief. 
Cracked  ice  in  the  mouth  is  also  beneficial.  If  the  pain  is 
severe,  cocain  (4  per  cent,  solution)  may  be  painted  on  the 
tongue.  For  the  swelling,  adrenalin  hydrochlorid  applied  to 
the  surface  of  the  tongue  is  recommended.  If  the  process 
continues  unabated,  free  incision  on  either  side  of  the  median 
line  becomes  necessary.  An  artificial  leech  applied  to  the  side 
of  the  jaw  may  be  used  to  relieve  the  congestion.  Severe  cases 
call  for  stimulation.  The  diet  during  the  course  of  a  severe 
infection  should  be  liquid,  and  rapidly  increased  as  the  dis- 
ease regresses.  The  cessation  of  symptoms  is  usually  accom- 
panied by  desquamation  of  the  epithelium  of  the  tongue. 

CHRONIC   GLOSSITIS. 

Continued  irritation  of  the  tongue,  caused  by  jagged  teeth, 
alcohol,  strong  caustic  drugs,  the  constant  chewing  of  tobacco, 
or  persistent  gastro-intestinal  disorders,  tuberculosis  and 
syphilis  may  result  in  a  low-grade  inflammation  of  the  super- 
ficial or  deep  structures  of  the  tongue.  The  epithelium  is 
thickened;  the  heaping  of  the  cells  tends  to  obliterate  the 
capillary  interspaces,  with  more  or  less  linear  streaks  of 
normal  tongue  surface,  dividing  it  into  irregular  whitish  areas. 
In  other  cases  the  epithelium  is  atrophied,  with  reddish 
patches,  round,  oval,  or  irregular,  scattered  over  the  surface 
of  the  tongue. 

Geographical  Tongue.  This  disorder  is  thus  named  be- 
cause it  appears  to  resemble  geographical  charts.  There  are 
various  sized  denuded  epithelial  areas,  the  centers  of  which 
appear  to  have  normal  epithelial  cells.  The  outer  borders  are 
whitish  or  yellow,  changing  in  appearance  and  spreading  over 
the  tongue.  Desquamation  may  also  occur  on  the  edges  of 
the  tongue,  causing  it  to  appear  roughened  and  red.  This 
condition  occurs  chiefly  in  children,  and  is  sometimes  known 
as  ringworm  or  eczema  of  the  tongue.  The  subjective  symp- 
toms are  a  sense  of  burning  and  slight  occasional  pain. 

In  superficial  glossitis  and  in  geographical  tongue  the  usual 


670  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

alkaline  washes  already  mentioned  for  mouth  infections  are 
recommended.  A  2  per  cent,  solution  of  silver  nitrate  may 
be  painted  over  painful  or  fissured  areas.  The  exciting  cause 
of  the  disease  should  be  thoroughly  investigated,  more  espe- 
cially the  teeth.  If  the  tongue  is  tuberculous  or  syphilitic,  as 
indicated  by  the  history  and  laboratory  findings,  the  treatment 
should  be  directed  toward  these  special  diseases. 

Gumma  of  the  tongue  should  be  suspected  if  one  or 
more  localized  round  or  flat  areas  of  induration  are  associated 
with  a  definite  history  and  laboratory  findings  of  syphilis. 
These  gummatous  areas  var}^  in  color  from  pink  to  dark  red ; 
later  the}^  break  down  and  ulcerate,  leaving  ugly,  punched  out, 
raw  surfaces.    Pain  is  slight  or  absent. 

The  internal  administration  of  arsenobenzol  or  arsphena- 
mine  is  indicated.  The  iodids  are  very  valuable  in  gumma- 
tous formations. 

Tuberculosis  of  the  tongue  manifests  itself  by  the  ap- 
pearance of  tubercles  on  the  tip  or  edge  of  the  tongue,  with 
subsequent  ulceration  and  the  development  of  discharging 
painful  denuded  areas.  These  ulcerations  should  be  treated 
by  the  local  application  of  silver  nitrate  (10  per  cent.),  pure 
carbolic  acid,  trichlorascetic  acid,  or  tincture  of  iodin. 

Leucoplakia  (white  tongue)  is  a  chronic  superficial  patho- 
logic condition  of  the  tongue  manifested  by  the  appearance 
of  hard  raised  whitish  patches,  which  are  smooth  or  fissured.  This 
condition  is  usually  found  among  male  adults  who  are  habitual 
smokers,  and  in  persons  whose  teeth  are  decayed  or  have 
irregular  broken  surfaces.  Gastro-intestinal  disorders,  skin 
diseases,  with  special  mention  of  psoriasis  and  other  scaly  con- 
ditions, may  be  associated.  It  is  claimed  that  leucoplakia  in 
a  fair  proportion  of  cases  is  followed  by  cancerous  implanta- 
tion. The  condition  begins  as  smooth  red  patches  on  the 
anterior  surface  of  the  tongue,  and  sometimes  on  the  lips, 
cheeks,  gums,  and  palate.  These  patches  tend  to  coalesce,  but 
usually  are  limited  to  the  area  of  the  tongue  anterior  to  the 
circumvallate  papilla.  They  cause  little  or  no  subjective 
symptoms  except  when  fissured,  in  which  case  there  is  more 
or  less  pain. 


TUMORS  OF  THE  TONGUE.  671 

TREATMENT. 

The  treatment  should  be  directed  toward  eliminating  the 
exciting  causes.  Sharp,  irritating  teeth  should  be  removed, 
or  properly  attended  to  by  the  dentist.  Smoking  should  be 
gradually  reduced  in  frequency,  and  finally  abandoned.  The 
usual  alkaline  mouth-washes  are  valuable  in  that  they  keep  the 
mouth  clean,  sweet,  and  fresh.  Alcohol  should  be  forbidden. 
Chromic  acid  solution  (2  per  cent.)  may  be  applied  locally  over 
the  areas  to  facilitate  exfoliation  of  the  plaques.  Salicylic 
acid  (1 :  1000)  is  also  recommended  for  this  purpose. 

SUBLINGUAL    ULCER. 

This  condition  is  often  found  in  children  affected  by 
whooping-cough.  It  is  believed  to  be  due  to  irritation  caused 
by  the  teeth  during  the  act  of  coughing.  It  is  usually  located 
at  the  frenum  of  the  tongue.  No  special  treatment  is  indi- 
cated other  than  the  use  of  the  usual  alkaline  mouth-washes. 

TUMORS    OF   THE   TONGUE. 

Carcinoma  not  infrequently  afifects  the  tongue.  Pipe 
smokers  and  tobacco  chewers  are  susceptible,  and  traumatism 
or  constant  irritation  of  the  tongue  predisposes  to  the  stimu- 
lation of  the  tissues  with  cancer  formation.  Every  ulceration 
or  papillomatous  growth  of  the  tongue  should  be  looked  upon 
with  suspicion  as  a  precursor  of  a  potential  malignant  growth. 
If  associated  with  enlargement  of  the  submaxillary  or  post- 
cervical  glands,  the  diagnosis  of  cancer  is  very  likely. 

All  ulcerations  of  the  tongue  should  be  treated  with  appli- 
cations of  silver  nitrate,  10  grains  to  the  ounce  (0.65  Gm.  to  30 
mils),  while  all  papillomatous  growths  of  epithelial  heapings 
should  be  examined  microscopically  by  making  sections  of  the 
affected  parts.  Cancerous  processes  should  be  treated  either 
by  fulguration  or  by  excision  of  the  tongue. 

Among  other  growths  of  the  tongue  may  be  mentioned 
sarcoma,  lymphangioma,  hemangioma,  lipoma,  and  fibroma. 
All  these  conditions  are  surgical  and  are  therefore  not  to  be 
considered  here. 


672  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

MACROGLOSSIA. 

This  is  a  general  enlargement  of  the  tongue  associated 
with  cretinism.  The  treatment  is  directed  toward  the  thyroid 
deficiencies.     (See  Vol.  ii.  p.  104.) 

DISEASES  OF  THE  SALIVARY  GLANDS. 

PTYALISM. 
(Hypersecretion.) 

An  increased  flow  of  saliva  ma)-  occur  during  the  men- 
strual periods,  in  the  early  days  of  pregnancy,  in  certain  men- 
tal states,  such  as  hysteria  and  mania,  in  exophthalmic  goiter, 
and  during  the  administration  of  drugs  like  mercury  and 
iodids. 

A  moderate  increase  of  saliva  needs  no  special  treatment, 
but  when  the  condition  become  annoying  and  distressing  to 
the  patient,  tincture  of  belladonna  may  be  given,  5  to  10  drops 
(0.30  to  0.60  mil)  every  three  hours,  until  comparative  dryness 
is  produced.  It  is  necessar}',  however,  to  ascertain  the  cause 
in  each  instance,  and  remoA'e  it  if  practicable. 

XEROSTOMA. 
(Dry  Mouth.) 

A  decreased  secretion  of  the  salivary  glands  may  occur 
after  mumps,  at  the  time  of  the  menopause,  in  diabetes,  and 
in  neurasthenia.  As  a  result  of  decreased  salivation,  the 
tongue  becomes  dry  and  fissured,  and  the  entire  mucous  mem- 
brane becomes  parched.  The  disease  is  rather  uncommon. 
Salivation  may  be  stimulated  by  the  use  of  the  faradic  current 
over  the  salivary  glands,  and  by  the  internal  administration  of 
pilocarpin  nitrate,  %o  grain  (0.00324  Gm.)  in  water,  three 
times  a  day. 

INFLAMMATION    OF    THE    PAROTID    GLANDS. 

The  subject  of  mumps  has  already  been  considered  under 
the  Specific  Infections.  (See  \'ol.  i.  p.  110.)  The  parotid  glands 
may  become  the   seat  of  inflammatory  changes  during  the 


SALIVARY  CALCULI.  673 

course  of  the  various  infectious  diseases,  especially  in  typhoid 
fever  and  pneumonia.  It  may  be  secondary  to  suppurative 
conditions  in  the  kidneys  or  liver,  or  follow  certain  abdominal 
operations.  Infection  occurs  through  the  blood,  or  by  conti- 
nuity of  tissue  through  Stenson's  duct.  The  infection  may 
result  in  enlargement  of  the  gland,  attended  with  pain  on 
swallowing-,  with  complete  resolution  in  a  few  days.  In  other 
instances  suppuration  may  occur,  with  rupture  of  the  abscess 
mass,  either  externally  through  the  skin,  or  internally  into  the 
mouth,  ear,  or  even  into  the  middle  fossa  of  the  skull.  Infec- 
tion may  also  travel  through  the  tissues  of  the  neck,  extend- 
ing as  far  as  the  clavicle,  or  even  into  the  mediastinal  spaces 
of  the  chest. 

When  parotitis  occurs  in  the  course  of  another  infection, 
it  causes  an  increased  rise  in  the  temperature,  pain  and  dis- 
comfort on  chewing,  and  prolongs  the  course  of  the  original 
disease. 

TPEATMENT. 

Great  relief  may  be  obtained  from  hot  applications,  either 
in  the  form  of  hot  stupes  (one  tablespoonful  (15  Gm.)  of 
Epsom  Salts  to  a  quart  (1  1.)  of  hot  water),  hot  water  bottle, 
electric  pad,  flaxseed  poultice,  or  hot  salt  bag  (salt  heated  in 
pan  and  then  placed  in  original  salt  bag).  Ichthyol  ointment 
may  also  be  applied.  When  the  affection  has  progressed  to 
the  stage  of  suppuration,  the  pus  must  be  evacuated  by  an 
incision  over  the  most  prominent  part  of  the  fluctuating  mass. 
While  free  and  early  incision  is  recommended  in  ordinary  ab- 
scess of  other  parts  of  the  body,  it  is  advisable  in  this  instance 
that  incision  be  delayed  until  the  abscess  mass  points,  in  order 
to  avoid  a  sinus  formation,  which  may  result  when  cutting 
into  healthy  glandular  tissue.  In  the  case  of  females,  it  is 
often  advisable  to  open  the  abscess  mass  through  the  mouth 
to  avoid  the  possibility  of  scarring  the  face. 


SALIVARY    CALCULI. 

Salivary  calculi,  composed  of  calcium  carbonate  phosphate, 
may  occasionally  be  found  in  the  salivary  ducts  or  in  the  sub- 
Stance  of  the  glands.    The  treatment  is  surgical. 

43 


674  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 


LUDWIG'S    ANGINA. 

Ludwig's  angina  is  a  cellulitis  of  the  floor  of  the  mouth, 
characterized  by  swelling  of  the  submaxillar}-  regions,  either 
unilateral  or  bilateral,  which  later  may  extend  to  the  soft 
tissues  between  the  mandibles,  and  reach  the  anterior  surface 
of  the  neck  as  far  as  the  sternum.  It  is  an  infection  of  the 
submaxillary  glands  and  adjacent  cellular  tissue,  caused  by 
the  invasion  of  pathogenic  micro-organisms  through  the  lym- 
phatics. An  abrasion  in  am-  part  of  the  mucous  membrane  of 
the  mouth  or  a  carious  tooth  may  be  the  precipitating  agent. 

At  the  onset  of  the  infection  the  fever  is  moderate,  but 
rises  as  the  disease  extends,  especially  when  attended  with 
abscess  formation.  The  skin  surface  of  the  chin  becomes 
tense  and  full,  edematous,  and,  later,  hard  to  the  touch.  Chew- 
ing and  swallowing  become  painful.  If  the  disease  extends, 
as  it  may,  to  the  larynx,  or  to  the  lungs,  symptoms  of 
asphyxiation  become  prominent. 

Treatment.  Hot  applications  are  quite  acceptable.  Stupes 
of  Epsom  salts  applied  ever\-  twentv"  minutes  in  the  hour  tend 
to  favor  resolution.  Hot  and  cold  applications  may  be  alter- 
nated. AA'hen  the  swelling  is  intense,  with  or  without  suppur- 
ation, deep  incisions  on  either  side  of  the  median  line  should 
be  made  to  drain  the  parts  of  their  infectious  material. 


DISEASES  OF  THE  ESOPHAGUS. 

ACUTE    ESOPHAGITIS. 

Being  the  passage-way  of  food  and  drink,  the  esophagus 
may  be  subject  to  traumatism  and  injury  by  irritating  drinks, 
caustic  liquids,  sharp-edged  solid  foods,  froeign  bodies,  and 
the  extension  of  inflammation  from  adjacent  parts.  Acute  in- 
fection may  result  during  the  course  of  acute  systemic  dis- 
eases, such  as  syphilis  and  tuberculosis.  Diphtheria  and 
thrush  may  also  inflame  this  region  in  rare  instances.  Injure- 
to  the  gullet  by  foreign  bodies  is  quite  common  in  children. 
In  adults,  injur}*  occurs  among  dressmakers,  who  constantly 
hold  pins  in  their  mouths ;  among  window-dressers,  carpet  or 


ULCER  OF  THE  ESOPHAGUS.  675 

oilcloth  layers,  who  have  the  habit  of /holding  tacks  in  the 
mouth ;  and  among"  the  insane,  who  may  swallow  various  ob- 
jects, varying-  in  size  from  tacks  and  pins  to  large  nails, 
screws,  and  other  metal  objects. 

The  characteristic  symptom  is  pain,  exaggerated  on  taking 
food.  In  severe  types  all  food  may  be  rejected  by  retching 
and  vomiting. 

TREATMENT. 

The  treatment,  of  course,  calls  for  the  removal  of  the  cause, 
followed  by  careful  dietary  of  non-irritating  substances.  At 
first  lukewarm  foods  should  be  given,  such  as  milk,  broths, 
beef  tea,  weak  tea,  and  later  there  may  be  added  buttermilk, 
gelatin,  junket,  custards,  and  tapioca  pudding.  If  the  pain  is 
severe,  all  food  should  be  withdrawn  for  from  twenty-four  to 
forty-eight  hours.  Enteroclysis  of  salt  solution  may  be  sub- 
stituted to  supply  the  necessary  fluid  for  the  body.  To  allay 
the  acute  pain,  oilve  oil,  cream,  or  milk  may  be  used  as  suit- 
able demulcents.  Intense  burning  of  the  esophagus  is  usually 
associated  with  some  condition  of  the  mouth,  which  makes 
swallowing  very  painful,  and  ofttimes  very  difficult.  In  such 
cases  bismuth  subcarbonate  20  grains  to  the  ounce  (1.3  Gm. 
to  30  mils)  of  water  may  be  administered  slowly  as  a  pro- 
tective coating.  Sippy^  recommends  the  administration  of  a 
teaspoonful  {Z.7  mils)  of  adrenalin  hydrochlorid,  1 :  1000,  con- 
taining 1  per  cent,  cocain,  just  'before  feeding. 

Cicatrization  of  the  tissues  following-  caustic  burns  is  in- 
evitable. It  is,  therefore,  advisable  to  use  esophageal  bougies 
about  ten  days  after  the  injury  to  prevent  the  possibility  of 
stenosis.  The  size  of  these  dilators  should  be  judged  from 
the  extent  of  the  scar  tissue  contraction,  and  gradually  in- 
creased to  the  full  diameter  of  the  esophagus. 

ULCER    OF    THE    ESOPHAGUS. 

Erosions  of  the  mucosa  and  subjacent  tissues  of  the 
esophagus  may  follow  simple  esophagitis,  or  may  result  from 
the  corrosive  action  of  poisons  and  acids,  from  the  abrasion 
of  foreign  bodies,  from  the  invasion  of  disease  processes  such 
as  syphilis,  tuberculosis,  or  actinomycosis,  from  the  pressure 
of  growths  in  neighboring  organs,  from  regurgitation  of  di- 


()J()  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

gestive  juices  of  the  stomach,  and  from  a  lowered  vital  state 
during  the  course  of  acute  affections  or  chronic  cachectic 
states.  Pain  is  a  prominent  symptom,  and  occurs  immediately 
after  deglutition.  Localized  behind  the  sternum,  and  referred 
to  the  back,  it  may  be  difficult  to  take  solid  foods,  or  even 
liquids.  The  passage  of  food  over  the  irritated  surface  may 
cause  spasm  of  the  esophagus.,  resulting  in  regurgitation  of 
food.  The  vomitus  may  be  blood-stained,  or  may  contain 
bright  red  blood.  The  ulcerated  area  on  some  ocT:asions  rup- 
tures, and  this  is  attended  with  hemorrhage  into  the  stomach 
or  externally  through  the  mouth.  In  such  an  event  the  prog- 
nosis is  less  favorable. 

Ulceration  of  the  esophagus  at  the  lower  third  may  occur 
as  the  result  of  insufficiency  of  the  cardiac  sphincter,  per- 
mitting the  gastric  juices  to  enter  the  esophagus.  The  lesion 
in  this  area  is  called  peptic  ulcer,  and  is  infrequent  in  occur- 
rence. In  this  instance  the  pain  is  most  acute  at  the  end  of 
deglutition,  and  is  localized  over  the  end  of  the  sternum,  and 
referred  to  a  corresponding  area  over  the  spine. 

Tuberculous  and  syphilitic  ulcers  are  rare,  and  are  diag- 
nosed by  appropriate  laboratory  tests. 

TREATMENT. 

In  cases  of  mild  ulceration,  liquids  foods  are  tolerated. 
Severe  cases,  however,  may  require  the  withdrawal  of  all 
foods  by  mouth  for  from  twenty-four  to  forty-eight  hours.  In 
this  instance  fluid  may  be  supplied  to  the  body  by  enteroclysis, 
and  occasional  rectal  feeding  with  peptonized  milk.  When 
the  pain  subsides,  the  patient  may  be  given  milk,  junket,  gel- 
atin, tapioca  pudding,  soup,  meat  broths,  ice  cream,  and  water 
ices.  Bismuth  subnitrate  or  carbonate,  10  to  20  grains  (Gms. 
0.65  to  1.3),  may  be  given  three  times  a  day  in  water  or  milk.- 
Rest  in  bed  is  quite  essential  during  the  acute  inflammatory 
stage.  Ulcerations  at  the  cardiac  end  of  the  esophagus  are 
to  be  treated  in  like  manner  as  those  occurring  in  the  cardiac 
end  of  the  stomach.  (See  Gastric  Ulcer,  Vol.  ii.  p.  695.)  If 
the  disease  is  of  such  an  extent  that  the  patient  is  unable  to 
take  nourishment  for  an  extended  period  of  time,  and  is  at- 
tended with  loss  of  weight,  and  in  cases  where  hemorrhage 
is  severe,  it  is  advisable  to  perform  a  gastrostomy. 


CARCINOMA  OF  THE  ESOPHAGUS.  677 

CARCINOMA    OF    THE    ESOPHAGUS. 

The  most  frequent,  serious,  and  fatal  disease  of  the  esopha- 
gus is  cancer.  It  occurs  most  frequently  in  males  over  forty 
years  of  age.  The  lower  end  of  the  esophagus  is  most  often 
affected,  although  a  large  number  of  cases  occur  in  the  region 
of  the  bifurcation  of  the  trachea,  and  a  smaller  number  in  the 
cervical  region.  Their  structure  may  be  of  the  soft  medullary 
type,  or  fibrous  in  charcater.  The  growth  usually  encircles 
the  esophagus,  causing  varying  degrees  of  stenosis.  The  pa- 
thology depends  upon  the  type  of  the  growth  and  the  pre- 
dominant structures.  It  does  not  differ  materially  from  cancer 
in  other  parts  of  the  body.  Carcinoma  selects  the  esophagus 
because  this  organ  is  frequently  subject  to  traumatism,  and 
because  its  embryonic  structure  may  include  a  few  superfluous 
cells  which  later  develop  into  a  tumor  mass  of  the  entoderm. 
The  most  prominent  symptom  is  dysphagia,  which  becomes 
more  marked  as  the  stenosis  increases.  Vomiting  of  mucus, 
blood,  and  disintegrated  tissue  occurs.  The  cervical  glands 
become  enlarged.  Metastasis  takes  place  in  the  liver,  lungs, 
pleura,  pericardium,  and  the  lymph  nodes  along  the  thoracic 
aorta.  The  disease  is  generally  fatal  in  from  six  months  to 
one  year. 

Ulceration  and  maceration  of  the  tumor  mass  may  be  at- 
tended by  perforation  into  a  bronchus,  the  aorta,  or  pericar- 
dium, causing  extensive  hemorrhage  and  bloody  vomitus.  As 
the  disease  progresses,  feeding  becomes  more  difficult.  There 
is  extreme  loss  of  weight  from  inanition  and  cachexia,  and  the 
patient  presents  symptoms  as  in  carcinoma  of  other  regions. 
This  disease  ofttimes  simulates  simple  stricture,  caused  by 
pressure  from  adjacent  organs,  or  by  mechanical  or  chemical 
Irritation.  The  diagnosis,  however,  is  determined  by  the  pro- 
gressive cachexia  in  a  patient  past  middle  life,  and  the  finding 
of  carcinoma  tissue  in  the  vomitus.  X-ray  diagnosis  is  of 
great  importance  in  the  differentiation. 

TREATMENT. 

Early  diagnosis  calls  for  careful  and  judicious  manipula- 
tion by  bougies.  This  may  give  material  comfort  to  the  pa- 
tient by  stretching  the  contracted  lumen.     Since  maceration 


678  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

of  the  diseased  tissues  may  be  caused  by  passing  bougies,  it  is 
advisable  that  their  use  be  restricted  to  those  familiar  with 
the  procedure.  Dilatation  should  be  performed  weekly.  In 
spite  of  these  treatments,  however,  which  are  only  palliative, 
the  dysphagia  increases,  and  the  vomiting  and  bleeding  be- 
come more  frequent.  Every  possible  measure  should  be 
adopted  to  give  the  patient  comfort  and  ease.  The  food 
should  be  liquid  and  nourishing,  consisting  of  articles  such  as 
milk,  buttermilk,  eggs,  custards,  gelatin,  tapioca  pudding, 
floating  island,  ice  cream,  and  water  ice.  Proper  and  constant 
nursing  tends  to  make  the  patient  more  at  ease. 

If  there  is  considerable  pain,  rectal  feeding  with  peptonized 
milk  should  be  given  for  several  days.  If  the  stricture  has  so 
far  progressed  as  to  cause  rejection  of  all  food,  and  emaciation 
increases,  a  gastrostomy  is  demanded.  The  surgical  treat- 
ment of  this  condition  has  not  as  yet  developed  suf^ciently  to 
risk  the  opening  of  the  chest  and  resecting  the  diseased  por- 
tions of  the  esophagus.  If  there  is  severe  hemorrhage,  and 
starvation  is  threatened,  surgical  intervention  is  indicated, 
with  a  view  to  creating  an  artificial  sinus  between  the  stomach 
and  abdominal  wall,  through  which  the  patient  may  be  fed. 
In  some  instances  the  esophagus  immediately  above  the  stric- 
ture becomes  dilated,  creating  a  pocket  where  food  lodges  and 
becomes  decomposed.  Mucus,  pus,  and  blood  may  also  accu- 
mulate in  this  dilated  portion.  In  such  instances  the  esopha- 
gus should  be  washed  out  once  daily  with  salt  solution  or  boric 
acid.  The  A'-ray  treatment  may  be  of  some  value  in  the  hands 
of  experts. 

Much  has  been  done  recently  along  the  lines  of  radium 
therapy.  This  preparation,  however,  is  quite  expensive,  and 
is  not  within  the  reach  of  all.  Its  use  is  restricted  to  those 
who  are  most  expert  in  handling  it. 

ESOPHAGISMUS. 

Occasionally  the  muscular  structure  of  the  esophagus  is 
subject  to  tonic  or  clonic  contraction,  which  is  precipitated  re- 
flexively  by  ulcers  of  the  lar\mx,  gastric  disturbances,  uterine 
or  other  abdominal  irritations.  It  may  be  an  accompanying 
symptom  in  hysteria,  neurasthenia,  tetanus,  hydrophobia,  epi- 


DIVERTICULUM  Ul-  THE  ESOPHAGUS.  679 

lepsy,  and  highly  neurotic  states.  The  principal  symptom  is 
dysphagia.  While  liquids  can  generally  be  taken,  solids  can- 
not. There  is  pain  over  the  sternum,  and  a  sense  of  choking. 
Other  symptoms  are  those  referable  to  the  cause  producing 
the  esophagismus.  Spasm  may  occur  at  the  pharyngeal  or 
cardiac  end,  or  at  any  place  in  its  length,  the  first  two  sites 
being  the  most  common. 

Obstruction  of  the  pharyngeal  end  is  readily  overcome  by 
the  passage  of  large-sized  objects.  When  it  occurs  in  the 
course  of  the  esophagus,  the  systematic  passage  of  bougies 
readily  overcomes  the  difficulty.  Sometimes  medication  with 
bromids  will  be  sufficient  to  cause  relaxation.  The  systemic 
condition  of  the  patient  should  be  treated  as  a  preventive 
measure  from  future  attacks.  Stricture  of  the  lower  end  is 
commonly  called  cardiospasm,  and  is  discussed  under  Diseases 
of  the  Stomach  (q.v.).         » 

DIVERTICULUM    OF   THE    ESOPHAGUS. 

Sacculation  of  any  part  of  the  esophagus  may  occur  as  the 
result  of  pressure  or  traction  upon  its  walls.  The  pouchings 
are  anatomically  constructed  of  mucous  membrane  and  con- 
nective tissue.  It  is  in  reality  a  hernia,  which  pushes  aside 
the  muscle  fibers  retaining  its  coat  of  mucous  membrane  and 
submucous  tissue.  The  contents  of  the  sac  may  be  either 
fluid,  solid,  or  both.  A  congenital  deficiency  of  the  brachial 
clefts  of  the  embryonic  structures  may  predispose  to  saccula- 
tion. Acquired  hernias  of  the  esophagus  are  due  to  pressure 
from  within,  with  lowered  resistance  of  the  muscular  tissue. 
Repeated  pressure  of  solid  foods  over  the  same  weakened  area 
constantly  increases  the  sacculation,  until  a  well-formed,  pear- 
shaped  diverticulum  results.  Injury  or  previous  inflammation 
may  be  a  contributing  cause.  Sacculation  occurs  most  fre- 
quently at  the  junction  of  the  pharynx  and  esophagus  in  the 
posterior  aspect,  but  may  also  occur  in  the  pharynx  near  the 
bifurcation  of  the  trachea,  and  above  or  below  the  left  bron- 
chus. It  occurs  more  frequently  among  males  of  middle  adult 
life. 

Traction  diverticula  result  from  adhesions  of  adjacent  tis- 
sues to  the  esophagus  following  inflammatory  lesions,  such 


680  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

as  bronchial  adenitis  with  suppuration.  These  diverticula  are 
funnel-shaped,  and  are  located  in  the  upper  end  of  the  esoph- 
agus, anterior  and  near  the  tracheal  bifurcation.  They  do  not 
usually  produce  subjective  symptoms,  while  the  pressure 
hernias  (less  common  in  occurrence)  give  rise  to  well-defined 
clinical  symptoms.  If  ulceration  takes  place  in  traction  sac- 
culations as  the  result  of  retained  food  particles,  perforation 
may  take  place  into  the  bronchi,  pleural  sacs,  or  rarely  into 
the  pericardium. 

.Sacculations  resulting  from  pressure  of  food  may  often 
escape  notice  if  very  small,  but  give  rise  to  a  chain  of  clinical 
symptoms  when  large.  Painful  swallowing  is  commonly  com- 
plained of,  but  its  degree  depends  upon  the  size  of  the  saccu- 
lation and  its  location.  As  the  diverticulum  increases  in  size, 
vomiting  becomes  more  frequent,  with  symptoms  of  threat- 
ened strangulation.  The  vomited  material  contains  no  gastric 
juice.  This  special  point  tends  to  dififerentiate  gastric  dis- 
orders. When  the  sacculation  becomes  especialh^  large,  a 
pear-shaped  mass  may  be  palpated  in  the  side  of  the  neck. 
Pressure  on  the  larynx  causes  dyspnea,  pain,  spasmodic  cough- 
ing, and  changes  in  the  voice.  The  patient  himself  may  com- 
plain of  food  lodging  in  a  certain  part  of  the  esophagus.  The 
condition  tends  to  progress,  the  symptoms  become  exagger- 
ated, and  malnutrition  results. 

The  diagnosis  is  made  by  the  passage  of  a  sound,  which  is 
arrested  by  the  sac.  Verj^  often  the  sac  orifice  is  small  or  tor- 
tuous, in  which  case  tlhe  investigating  bougie  may  enter  the 
stomach  directly.  After  eating,  the  sac  usually  enlarges  and 
may  be  emptied  by  pressure  of  the  hand.  A  bismuth  meal 
followed  by  ,f-ray  and  fluoroscopic  examination  may  locate  the 
lesion. 

Unless  the  condition  is  relieved  by  surgical  means,  death 
takes  place  by  starv-ation  or  intercurrent  afifections.  The  pa- 
tient, however,  should  be  instructed  to  eat  liquids  or  semi- 
solids, and  to  do  so  very  slowly,  in  small  quantities,  and  at 
frequent  inter\^als.  Retained  and  decomposed  food  in  the  sac- 
culation should  be  washed  out  daily  b}^  irrigations  of  boric 
acid  solution  or  potassium  permanganate  (1:1000).  When 
located  in  accessible  regions,  surgical  intervention  may  be 
attempted.    When  the  sacculation  increases  so  as  to  impinge 


STRICTURE  OF  THE  ESOPHAGUS.  681 

upon  the  trachea,  the  esophagus,  and  adjacent  organs,  the 
prognosis  becomes  very  grave.  The  lumen  of  the  sac  may 
become  obstructed  by  twisting  or  by  pressure,  in  which  case 
it  becomes  difficult  to  remove  the  contents.  The  patient 
should  try  feeding  in  various  postures  to  encourage  peristal- 
sis of  the  esophagus.  It  may  be  necessary  to  pass  a  perforated 
bougie  for  the  purpose  of  administering  nourishment.  If 
starvation  is  threatened,  gastrostomy  must  be  performed. 

FOREIGN  BODIES. 

Foreign  bodies  are  frequently  swallowed  by  children,  and 
may  become  lodged  in  any  part  of  the  esophagus,  most  fre- 
quently below  the  cricoid  cartilage.  Pennies,  buttons,  bones, 
stones,  pins,  and  various  other  objects  have  been  found  lodged 
in  the  esophagus.  Adults  may  accidentally  swallow  safety- 
pins,  false  teeth,  fish  bones,  peach  stones,  and  other  objects. 
If  not  removed  early,  they  may  cause  damage  to  the  esopha- 
geal walls,  and  produce  ulceration  of  the  tissues,  edema, 
necrosis,  and  infection  of  the  adjacent  tissues.  Death  may 
result  from  extensive  edema,  obstruction,  and  infection.  For 
this  reason  it  is  absolutely  essential  that  all  foreign  bodies 
should  be  removed  as  soon  as  possible  after  the  accident. 

Pennies  and  safety-pins  frequently  lodge  below  the  cricoid 
Cartilage,  and  require  great  skill  on  the  part  of  the  operator 
to  remove  them.  An  especially  devised  esophageal  forceps 
is  required  to  extract  foreign  bodies.  The  esophagoscope  may 
be  employed  to  explore  the  esophagus  and  to  direct  the  for- 
ceps to  grasp  the  foreign  body.  The  jr-ray  is  a  valuable  aid 
in  locating  the  foreign  bodies  capable  of  casting  a  shadow. 
The  fluoroscope  is  also  invaluable  to  note  the  progress  made 
during  the  intervals  of  attempted  extraction,     , 

STRICTURE  OF  THE  ESOPHAGUS. 

The  lumen  of  the  esophagus  may  be  constricted  at  any 
part  of  its  length  from  the  pharynx  to  the  stomach.  The 
causes  may  be  divided  as  those  from  within  and  those  from 
without.     Strictures  from  within  may  be  the  result  of: 

1.  The  corrosive  action  of  acids. 

2.  Cicatrization  of  ulcers. 


682  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

3.  Obstruction  by  foreign  bodies. 

4.  Cancer. 

5.  Syphilis  and  tuberculosis. 

6.  Polyps  and  diverticula. 

7.  Spasm  of  the  esophagus. 

Among  the  causes  from  without  may  be  mentioned  the 
various  growths  or  malpositions  of  viscera : 

1.  Aneurysm. 

2.  Mediastinal  tumors. 

3.  Thyroid  and  thymus  tumors. 

4.  Enlarged  cervical  glands. 

5.  Fracture  of  the  sternum,  ribs,  or  posterior  displacement 

of  the  sternum  end  of  the  clavicle. 

6.  Vertebral  abscess. 

7.  Displacement  of  the  heart  by  pericardial  exudates. 

8.  Cicatrices  in  the  tissues  of  the  esophagus. 

It  is  often  very  difficult  to  determine  the  nature  of  the 
obstruction.  A  careful  history,  however,  may  aid  in  the  diag- 
nosis. Slight  stenosis  may  cause  only  a  mild  discomfort  dur- 
ing swallowing,  giving  rise  to  a  sense  of  pressure  of  obstruc- 
tion behind  the  sternum,  especially  after  eating  solid  foods. 
As  the  stenosis  progresses  there  is  a  sense  of  obstruction  in 
the  epigastrium.  The  patient  often  notices  that  it  takes  a 
long  time  for  the  food  to  reach  the  stomach,  and  that  the  meal 
period  is  prolonged.  Regurgitation  of  the  food  may  occur 
immediately  after  eating,  or  several  hours  later.  Pain  is  pres- 
ent in  ulcerative  or  inflammatory  stenosis,  while  in  otiher  in- 
stances pain  may  be  absent.  As  the  stenosis  increases,  the 
symptoms  become  exaggerated,  and  are  accompanied  by  mal- 
nutrition and  debility.  The  diagnosis  may  be  confirmed  by 
watching  the  peculiar  attitude  of  the  patient  on  swallowing. 
The  passage  (Si  an  ordinary  stomach-tube  may  be  unhindered 
in  cases  in  which  the  stenosis  is  very  slight.  Moderate  con- 
striction, however,  may  be  detected  by  the  passage  of  a 
medium-sized  olive-tipped  esophageal  bougie,  the  precise  loca- 
tion of  the  obstruction  being  marked  on  the  bougie  when  the 
tip  becomes  arrested.  The  degree  of  stenosis  is  determined 
by  the  passage  of  sufficient  and  various  sized  bougies  until 
complete  passage  is  facilitated.  These  manipulations,  how- 
ever, should  only  be  performed  after  excluding  aneurysm  as  a 


STRICTURE  OF  THE  ESOPHAGUS.  683 

cause  of  the  obstruction.  On  auscultation  over  the  left  side 
of  the  spine  a  splashing-  or  a  flowing  sound  may  be  eKcited  at 
the  site  of  the  obstruction  when  the  patient  drinks  water. 
Differentiation  of  the  various  forms  of  stricture  must  be  made 
by  the  history.  Esophagismus  is  most  frequently  found  in  neu- 
rotic females,  and  may  be  relieved  by  the  systematic  passage 
of  bougies.  Gummatous  and  tuberculous  conditions  give  their 
respective  history  and  physical  findings.  Corrosive  strictures 
usually  give  other  evidence  of  burns  about  the  mouth. 
Malignant  obstructions  are  most  frequent  in  persons  over  the 
age  of  forty,  and  are  accompanied  by  progressive  signs  of 
cachexia. 

The  prognosis  of  cancerous  stricture  is  unfavorable.  While 
death  may  be  deferred  by  our  advanced  methods  of  treatment, 
permanent  cure  is  out  of  the  question.  Simple  strictures  may 
give  favorable  results  after  a  systematic  course  of  dilatation, 
but  most  strictures  tend  to  end  fatally. 

Cicatricial  stenosis  are  next  in  frequency  to  those  caused 
by  cancer.  Under  routine  and  regulated  dilatation,  fairly  sat- 
isfactory results  may  be  obtained.  Dilating  bougies  should  be 
used  as  early  as  the  first  week  following  caustic  burns.  After 
the  acute  symptoms  have  subsided,  an  olive-tipped  bougie 
should  be  passed  twice  weekly,  increasing  the  size  of  the  bulb 
until  the  full-sized  tip  makes  easy  passage.  It  may  be  neces- 
sary to  continue  the  dilatation  every  month  for  one  or  more 
years,  as  the  individual  case  may  require.  In  cases  of  spiral  or 
irregularly  shaped  strictures,  which  occur  not  only  in  the  lumen 
but  in  the  length  of  the  esophagus,  it  may  be  necessary  to 
resort  to  the  threaded  olive  bulb,  as  advocated  by  Sippy. 

Method  of  Passing  Whalebone  or  Steel  Rod  Bougie.  The 
patient  should  be  given  a  half-ounce  (15  mils)  of  olive  oil  be- 
fore the  operation,  in  order  to  facilitate  the  passage  of  the 
bougie.  A  4  per  cent,  solution  of  cocain  may  be  sprayed  over 
the  pharynx  to  prevent  spasm  and  gagging.  Place  the  patient 
in  a  comfortable  low  seat,  the  head  thrown  slightly  backward, 
and,  held  by  an  assistant,  who  faces  the  patient.  The  opera- 
tor, standing  beside  the  patient's  head,  inserts  the  finger  of 
the  left  hand  into  the  mouth  so  as  to  depress  the  tongue  until 
the  epiglottis  is  clearly  seen.  With  the  right  hand  the  opera- 
tor inserts  the  olive-tipped  bougie  along  the  epiglottis,  direct- 


684  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ing  it  into  the  esophagus.  Care  should  be  exercised  not  to 
make  a  false  passage  into  the  larynx.  The  bougie  is  passed 
with  steady  and  light  pressure.  The  touch  of  the  operator 
will  indicate  when  the  bulb  is  grasped  by  the  esophageal  mus- 
cles and  directed  downward.  Just  below  the  cricoid  cartilage 
the  tip  is  engaged  tightly  by  the  muscles.  If  an  obstruction 
is  met,  the  passage  is  hindered,  or  it  may  be  firmly  gripped  or 
entirely  obstructed.  Mark  the  bougie  even  with  the  teeth,  in 
order  thus  to  locate  the  distance  of  the  obstruction.  The 
normal  anatomic  locations  are  as  follows :  From  the  teeth 
to  the  cricoid  cartilage,  7  inches  (17.7  cm.)  ;  to>.the  left  bron- 
chus, 11  inches  (27.8  cm.)  ;  and  to  the  diaphragmatic  opening, 
15  inches  (37.9  cm.). 

DISEASES  OF  THE  STOMACH 
AND   DUODENUM. 

ULCER   OF   THE    STOMACH   AND    DUODENUM. 

The  term  gastric  or  duodenal  ulcer  is  applied  to  a  solu- 
tion of  continuity  of  the  mucous  membrane  of  the  stomach 
or  the  duodenum,  with  a  tendency  toward  a  penetrating  dis- 
integration and  necrosis  of  tissue.  Clinically,  there  is  a  strik- 
ing predilection  toward  sudden  remissions  of  symptoms  with 
equally  sudden  exacerbations. 

Ulcers  may  vary  from  the  superficial  erosions,  described 
by  Dieulafoy,  through  the  phagedenic  variety,  commonly 
seen  in  chlorotic  young  women,  to  the  true  peptic  ulcer,  more 
common  in  men,  which  has  a  tendency  to  a  deeper  penetra- 
tion and  greater  chronicity,  with  the  formation  of  indurated 
scar-tissue  edges. 

Three  etiologic  factors  have  been  generally  understood  to 
contribute  most  largely  to  this  condition:  (1)  Failure  of 
proper  nutrition  at  a  localized  point  of  the  mucous  membrane. 
(2)  Diminished  resistance  of  this  circumscribed  area  to  the 
action  of  the  peptic  power  of  the  gastric  secretions,  whether 
normal  or  increased.  (3)  The  efifect  of  the  mechanical  activ- 
ity of  the  stomach  musculature  in  the  pyloric  and  prepyloric 
portion,  where  the  greater  majority  of  these  ulcers  occur. 
More  recent  experimental  work  has  shown  that  there  are  two 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  685 

further  etiologic  factors  of  importance  that  must  be  con- 
sidered: (1)  a  toxemia  of  either  metabolic  or  bacterial  origin, 
and  (2)  the  contributing  effect  of  an  increased  intragastric 
tension,  excited  by  spasmodic  closure  of  the  orifices  of  the 
stomach. 

Turk  has  experimentally  produced  gastric  ulcer  by  the 
intravenous  injection  of  the  colon  bacillus.  More  recently 
Rosenow  has  reported  that  he  could  produce  gastric  and 
duodenal  ulcer  with  considerable  regularity  by  the  intraven- 
ous inoculation  of  certain  strains  of  streptococci,  and  he  lays 
emphasis  on  the  tonsils  as  being  an  important  source  of 
infection.  Nevertheless,  it  would  appear  that  the  human 
gastric  mucosa  is  much  more  resistant  to  true  bacterial  infec- 
tion than  is  that  of  the  experimental  animal;  nor  is  it  likely 
that  different  strains  of  the  same  bacterial  group,  so  beauti- 
fully shown  by  Rosenow  in  his  experimental  studies  to  have 
definite  selective  affinities  toward  the  production  of  gastric 
and  duodenal  ulcer  and  appendicitis,  can  so  uniformly  pro- 
duce similar  conditions  in  the  human  being.  Approaching 
the  problem  from  the  standpoint  of  a  metabolic  toxemia, 
Gundermann  has  experimentally  produced  both  acute  and 
chronic  ulcers  of  the  stomach  by  ligation  of  the  left  hepatic 
branch  of  the  portal  vein,  and  from  his  experiments  he  con- 
cludes that  hepatic  toxemia  can  initiate  the  ulceration.  These 
experimental  studies  strengthen  the  suspicion  that  the  close 
association  existing  between  the  simultaneous  occurrence  of 
a  gastric  or  duodenal  ulcer  with  a  chronically  inflamed  or 
obliterated  appendix,  and  somewhat  less  frequently  with  gall- 
bladder disease,  is  something  more  than  mere  coincidence. 

Circumscribed  malnutrition  of  the  gastric  or  duodenal 
mucosa  may  be  caused  by  localized  circulatory  failure,  as  a 
thrombosis  or  embolism  of  the  terminal  arterioles,  or  by  sud- 
den increase  in  intragastric  tension,  whereby  the  blood-supply 
is  diminished  or  cut  off;  by  the  action  of  corrosive  substances, 
and  by  the  selective  action  of  toxins  from  severe  burns.  Or 
the  malnutrition  may  arise  from  extragastric  organic  disease, 
giving  rise  to  passive  congestion  of  the  gastric  capillaries, 
with  the  formation  of  petechias,  submucous  hemorrhages 
and  infarcts;  and,  less  commonly,  from  traumatic  influences, 
chemical,    biochemical    or    parasitic,    from    within    or    from 


686  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

without,  as  from  sudden  blows  or  long-sustained  pressure 
over  the  stomach,  such  as  is  seen  in  tailors,  cobblers  or 
weavers. 

It  can  no  longer  be  maintained  that  hyperchlorhydria  is 
an  essential  in  the  production  of  the  ulcer,  although  it  doubt- 
less does  interfere  with  the  ready  healing  of  eroded  spots,  and 
in  some  cases  may  predispose  to  its  causation.  While  hyper- 
acidity is  the  rule  and  speaks  in  favor  of  ulcer,  yet  it  is  well 
to  remember  that  many  cases  of  gastric  and  duodenal  ulcer 
occur  in  the  presence  of  normal  acidity,  some  with  subacidity, 
but  few,  if  any,  with  anacidity. 

While  it  is  a  common  disease,  it  is  difficult  to  accurately 
estimate  its  frequency.  Even  in  recent  compilations  the 
surgeon's  statistics  differ  widely  from  those  of  the  clinician, 
and  it  is  not  difficult  to  explain  this.  The  surgeon's  statistics 
show  a  lesser  frequency,  inasmuch  as  they  deal  only  with 
those  cases  that  come  to  the  operating  table,  whereas  the 
clinician  sees  many  more  cases,  particularly  those  of  the  acute 
type  which  respond  to  medical  management.  Of  course,  there 
may  be,  and  doubtless  are,  a  certain  number  of  errors  in  the 
clinical  diagnoses,  but  this  applies  surgically  as  well  as  med- 
ically, for  in  these  days  there  is  an  increasing  number  of 
clinically  proven  cases  which  fail  to  be  corroborated  by  the 
exploring  eye  or  finger  of  the  surgeon,  which  later  on  develop 
unmistakable  clinical  symptoms,  such  as  hemorrhage.  In 
many  such  cases  the  failure  of  surgical  corroboration  is  due 
to  insufficient  exploration,  especially  in  ulcers  located  on  the 
posterior  wall,  or  to  the  inability  to  detect  minute  ulcers 
capable  of  giving  rise  to  symptoms,  but  not  sufficiently  pro- 
gressed to  give  evidence  of  scar-tissue  contracture  when 
viewed  from  the  serosal  surface  only.  The  tendency  of  some 
of  our  master-surgeons  to  do  an  intragastric  or  intraduodenal 
exploration  where  the  clinical  evidence  is  sound  is  a  tendency 
to  be  commended,  provided  that  if  in  the  future  such  a  pro- 
cedure can  be  shown  not  materially  to  increase  the  mortality. 
The  true  frequency  of  gastric  and  duodenal  ulcer  can  best  be 
gaged  by  the  finding  at  autopsy  of  gastric  or  duodenal  ulcers 
in  the  healed,  quiescent,  or  active  stages.  From  the  autopsy 
records  of  many  thousands  of  cases,  Welch  and  Fenwick 
respectively  estimate  its  frequency  as  being  5  per  cent,  and 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  687 

4  per  cent.,  although  it  could  be  determined  as  the  actual 
cause  of  death  in  less  than  1  per  cent. 

Probably  80  per  cent,  to  85  per  cent,  of  chronic  ulcers  are 
found  on  the  lesser  curvature,  near  the  pylorus.  They  are 
likely  to  straddle  the  lesser  curvature,  and  usually  show  more 
extensive  implication  of  the  posterior  than  the  anterior  sur- 
face. From  the  scars  and  open  ulcers  found  at  autopsy,  it  is 
probable  that  gastric  ulcer  is  much  more  common  than 
duodenal,  and  that  it  has  a  much  greater  tendency  to  spon- 
taneous cure,  which  somewhat  explains  the  surgical  statistics 
which  show  that  duodenal  ulcers  are  twice  as  common  as 
gastric  ulcers.  According  to  Mayo's  statistics,  the  site  of 
the  duodenal  ulcer,  in  96  per  cent,  of  their  cases,  was  in  the 
first  portion  of  the  duodenum  within  1  inch  of  the  pylorus. 

The  size  may  vary  from  scarcely  visible  erosions  to  ulcers 
measuring  3  to  5  centimeters  (1.18  to  1.96  in.)  in  diameter, 
with  occasional  reported  cases  of  ulcers  double  this  size. 
Chronic  ulcers  are  more  commonly  large  than  are  the  acute 
ones.     Duodenal  ulcers  are  usually  small. 

Duodenal  ulcers  are  almost  always  solitary,  whereas  in  20 
per  cent,  to  25  per  cent,  of  gastric-ulcer  cases  multiple  ulcers 
are  found.  In  about  3  per  cent,  of  the  Mayo's  cases  both 
gastric  and  duodenal  ulcers  were  found,  the  former  probably 
being  primary. 

As  to  sex  incidence,  statistics  vary.  Lockwood  summarizes 
it  as  follows :  "Acute  ulcer  of  the  stomach  is  three  times  as 
common  in  women  as  in  men,  that  in  chronic  ulcers  of  the 
stomach  the  proportion  between  the  two  sexes  is  equal,  while 
in  chronic  ulcer  of  the  duodenum  three-fourths  of  the  cases 
occur  in  men." 

Gastric  and  duodenal  ulcers  are  common  in  early  adult 
life,  most  acute  ulcers  occurring  in  the  second  or  third  decade, 
and  most  chronic  ulcers  giving  rise  to  symptoms  in  the  third 
and  fourth  decade.  Duodenal  ulcers  may  occur  in  the  very 
young,  Collins  having  reported  that  in  279  cases  collected  by 
him  15  per  cent,  were  under  10  years  of  age,  and  Moynihan 
has  called  attention  to  the  frequency  with  which  duodenal 
ulcer  may  be  the  Cause  of  melena  neonatorum. 

The  earlier  an  ulcer  is  recognized  and  placed  under  proper 
treatment,  the  more  likely  is  it  to  heal  rapidly,  and  to  stay 


688  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

healed.  Even  in  the  absence  of  all  treatment,  or  in  the  face  of 
poor  treatment,  many  ulcers  will  spontaneously  heal,  or,  at 
any  rate,  fail  to  give  rise  to  further  symptoms.  The  more 
superficial  the  ulcer  and  the  better  its  blood-supply,  the  more 
rapidly  will  it  heal,  with  or  without  treatment ;  the  deeper  the 
penetration  of  the  ulcer,  the  more  indurated  its  edges,  and  the 
extent  of  its  devascularity,  the  more  resistant  it  becomes  to 
medical  measures.  As  to  duration,  ulcers  may  run  a  course 
of  from  a  few  weeks  to  many  years.  Histories  of  twenty 
years  standing  are  not  infrequent,  and  some  cases  may  have 
lasted  even  longer.  It  is  a  disease,  perhaps,  most  signally 
characterized  by  its  chronicity  when  untreated,  and  by  the 
exacerbations  and  remissions  in  its  clinical  s3^mptoms. 

The  complications  incident  to  any  given  case  serve  to 
modify  the  prognosis  materially.  The  most  important  com- 
plications are  pyloric  obstruction  from  cicatrix,  inflammatory 
edema  or  pylorospasm;  continued  hypersecretion,  perigas- 
tritis or  perigastric  adhesions,  perforation  and  carcinomatous 
degeneration.  The  last  mentioned  is  the  most  dangerous, 
and,  therefore,  the  most  important.  According  to  Wilson 
and  MacCarty,9  it  is  the  most  frequent  complication  of  gas- 
tric ulcer,  occurring  in  from  40  to  50  per  cent,  of  cases,  but 
such  degeneration  is  rarely  seen  in  duodenal  ulcer. 

Criticism  of  these  statistics  has  arisen  on  the  grounds  that 
this  percentage  of  incidence  of  carcinomatous  degeneration  is 
much  too  high.  From  the  clinician's  standpoint  this  is  beside 
the  point.  Even  should  the  true  incidence  be  nearer  25  per 
cent,  than  50  per  cent,  it  is  sufficiently  high  to  make  us 
keenly  alive  to  its  seriousness,  and  if  the  time  now  spent  in 
splitting  hairs  over  such  a  statistical  controversy  were  applied 
to  a  closer  study  of  our  patients,  and  our  energies  bent  to  an 
elaboration  of  better  early  diagnostic  tests,  it  would  result  in 
far  more  profit  to  both  patient  and  physician. 

As  to  the  mortality,  comparative  statistics  are  unreliable, 
for  the  available  data  vary  within  wide  limits  in  the  hands 
of  experienced  observers  and  compilers.  The  surgical  mor- 
tality depends  primarily  upon  the  surgical  experience  and 
capability  of  the  individual  operator,  and  secondarily  upon 
the  type  of  surgical  complications,  the  duration  of  their  exist- 
ence, and  upon  whether  or  not  the  cases  for  operation  are 


ULCER  OF  THE  STOMACH  AND  DUODENUM. 


689 


selected.  In  the  hands  of  a  master-surgeon  the  mortality  is 
extremely  low.  The  writer  is  permitted  to  publish  the  fol- 
lowing statistical  tables  of  the  total  number  of  cases  of  gas- 
tric and  duodenal  ulcer  operated  upon  by  John  B.  Deaver 
during  the  past  six  years,  1909  to  1915,  inclusive.  During 
this  time  he  has  operated  upon  43  gastric  ulcers  (unperfor- 
ated)  with  2  deaths,  or  a  mortality  of  4.6  per  cent.;  179 
duodenal  ulcers  (unperforated)  with  6  deaths,  or  a  mortality 
of  3.35  per  cent. ;  9  gastric  ulcers  (perforated)  with  no  deaths; 
and  34  duodenal  ulcers  (perforated)  with  2  deaths,  or  a  mor- 
tality of  5.9  per  cent. ;  and  taking  the  total  number  of  per- 
forated ulcers,  gastric  and  duodenal,  with  2  deaths,  the  mor- 
tality is  reduced  to  4.6  per  cent,  and,  as  will  be  seen  by 
consulting  Table  No.  V,  the  mortality  occurred  in  cases  in 
which  perforation  had  taken  place  more  than  thirty  hours 
prior  to  operation.     The  complete  tables  are  as  follows : 


LANKENAU   HOSPITAL   STATISTICS. 

January,  1909— July,  1916. 

TABLE  No.  I. 

Gastkic    Ulcers. 

Operation.                                        Number.  Recovered.  Died.  Mortality. 

Post,  gastro-enterostomy  21                21  0  0 

Partial  gastrectomy   13                12  1  1 1  '^o 

Pylorectomy  2                  2  0  0 

Excision   5                  4  1  20      % 

Circular  resection   2                 2  0  0 

Total   43  41  2         4.6  % 


TABLE  No.  II. 

Duodenal   Ulcers. 

Operation.                                        JNumber.      Recovered.  Died.  Mortality. 

Post,  gastro-enterostomy  147  144  3  2     % 

Partial    gastrectomy    5  5  0  0 

Pylorectomy     24  22  2  8.3  % 

Excision     3  2  1  Zm,% 

Duodenorrhaphy    0  0  0  0 

Total    179  173  6  3.35% 

44 


690  DISEASES    OF    THE   DIGESTIVE    SYSTEM. 

TABLE  x\o.  III. 

Perforated  Gastric   Ulcer. 

Operation.                                      Number.     Recovered.  Died.     Mortality. 

Post,  gastro-enterostomy  6                 5  q          q        ' 

Gastrorrhaphy  3                  o  ^          „ 

"^^tal    9                 9  0         0     % 

TABLE  No.  IV. 

Perforated   Duodexal   Ulcer. 

P^cf            Ope-etion.                                       Number.     Recovered.  Died.     Mortality. 

Post,  gastro-enterostomy  24               23  1          5 1  % 

Partial  gastrectomy    4                 4  q          j.' 

Pylorectomy    1                   j  ^ 

Duodenorrhaphy    .■.'.■;       5                  4  1           20    % 


2         5.9  % 


Total    34  32 

TABLE  No.  V. 

Perforated   Duodenal   and   Gastric    Ulcers. 

Time  elapsing  between  perforation  and  operation : 
Duodexal    Ulcer. 

Hours.  No.  of  Cases.  Deaths. 

1-2  1  0 

3—6  9  0 

7-12  8  0 

13-24  7  0 

2 —  3  days  4  1 
More  than        4  days  5  1 

Gastric   Ulcer. 

3 —  6  hours  3  0 
7 — 12  hours                4  q 

13 — 24  hours  2  0 

Total        43  2  =  4.6% 

End  Results.  Traced  13  cases  (11  duodenal-2  gastric),  all  well  with- 
out  return  of  symptoms. 

No  inquiry  was  sent  to  3  cases  operated  in  1916. 

It  will  be  seen  from  a  revieAv  of  these  statistics  that  the 
mortality  is  exceedingly  low.  and  illustrates  what  can  be 
accomplished  by  a  master-surgeon  of  long  experience.  These 
statistics,  however,  cannot  be  taken  as  representative  of  the 


ULCER  OF  THE  STOMACH  AiND  DUODENUM.  691 

sur'gery  throughout  the  country,  which,  while  steadily  im- 
proving, has  not  reached  a  point  that  can  compare  statistic- 
ally with  the  foregoing. 

This  is  a  reiteration  of  what  the  writer  has  frequently 
emphasized,  namely,  that  in  the  selection  of  a  surgeon  for 
operations  of  the  stomach  or  upper  intestinal  tract,  other 
things  being  equal,  a  man  should  be  chosen  whose  formative 
period  of  perfecting  his  surgical  technic  has  been  passed,  and 
whose  judgment  is  a  result  of  years  of  surgical  experience. 

As  a  fundamental  antecedent  to  correct  treatment,  correct 
diagnosis  is  indispensable.  Differential  diagnosis  is  often 
exceedingly  difficult.  The  symptoms  commonly  ascribed  to 
gastric  and  duodenal  ulcer  are  very  frequently  simulated  by 
many  extragastric  organic  lesions,  which  reflexly  give  rise  to 
functional  disturbances  of  the  stomach.  There  should  be  a 
close  co-operation,  in  all  such  cases,  between  the  clinician, 
the  surgeon,  the  laboratory  expert,  and  the  rontgenographer, 
for  many  of  these  cases  need  intelligent,  systematic  investiga- 
tion. The  custom,  so  prevalent  in  the  past,  to  use  the  explora- 
tory laparotomy,  as  a  means  of  making  the  diagnosis,  is  a 
measure  to  be  strongly  deprecated,  and  happily  surgical  inter- 
ference of  this  sort  is  becoming  less  frequent.  Once  the  diag- 
nosis has  been  soundly  established,  the  next  important  point 
is  to  determine  whether  the  case  in  hand  should  be  treated 
medically  or  surgically,  'and,  if  the  latter,  whether  a  lapar- 
otomy should  be  done  at  once,  or  whether  a  preliminary 
medical  plan  should  be  adopted  for  a  trial  of  several  weeks 
or  several  months.  To  settle  this  the  clinician  must  establish 
the  following  points:  How  long  has  this  ulcer  existed?  Is 
it  an  open  or  a  closed  ulcer?  A  bleeding  or  non-bleeding 
one?    And  are  there  complications? 

Among  the  complications  and  sequelse  the  following  must 
be  considered : 

1.  Carcinomatous  degeneration  of  a  gastric  ulcer.  This 
is  the  first  and  most  important  complication,  and  a  frequent 
one,  when  the  ulcer  is  situated  on  the  gastric  side  of  the 
pylorus,  and,  aside  from  perforation,  is  the  one  immediate 
indication  for  prompt  surgical  intervention.  Where  the  ulcer 
is  on  the  duodenal  side  of  the  pyloric  ring,  the  chance  of  car- 
cinomatous degeneration  is  comparatively  remote. 


692  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

2.  Pyloric  obstruction.  Here  one  should  differentiate"  ob- 
struction caused  by  (a)  a  stenosing  cicatrix  shutting  off 
the  gastric  or  duodenal  lumen ;  (b)  inflammatory  edematous 
swelling;  (c)  perigastritis,  with  or  without  adhesions;  (c?) 
pylorospasm. 

3.  Hypersecretion. 

4.  Perigastric  abscess,  with  or  without  a  localized  peri- 
tonitis. 

5.  \'arious  contracting  deformities,  other  than  pyloric, 
such  as  hour-glass  contraction. 

6.  Hemorrhage:    acute  or  by  continued  minute  oozing. 
To    determine    the    various    complications    may    tax    one's 

diagnostic  acumen  to  the  utmost,  but  upon  it  depends  largely 
the  degree  of  success  in  the  treatment  of  such  cases. 

A  word  here  might  properl}^  be  said  in  regard  to  the 
proper  diagnostic  m-anenvers.  A  careful  examination  should 
be  made  of  both  gastric  and  duodenal  sediments,  for  blood, 
pus,  turbid  bile,  bacteria,  epithelial  desquamation,  etc.^o  One 
or  more  string  tests  to  aid  in  the  localization  of  the  ulcer  and 
to  determine  whether  it  is  bleeding;  extraction  of  the  gastric 
contents  to  determine  hypersecretion  should  be  made  at  the 
following  hours  of  the  fasting  stomach:  6  to  7  a.m.^  11  to  12 
A.M.^  5  to  6  p.M.^  and  11  to  12  p.m.  These  extractions  may 
best  be  made  with  any  small-bore  tube,  with  a  proper  metal 
tip,  and  aspirated  by  means  of  a  syringe ;  careful  examina- 
tions, chemical,  bacterial  and  cytologic,  and,  finally,  to  sup- 
port and  corroborate  these  facts  by  means  of  a  properly  made 
x-rzy  examination  of  the  intestinal  tract,  in  the  hands  of  an 
experienced  actinologist. 

The  Gluzinski  method  of  testing  the  gastric  secretory  re- 
sponse to  dift'erent  test-meals  is  one  of  considerable  aid  in 
differentiating  uncomplicated  gastric  ulcer  from  one  under- 
going carcinomatous  degeneration. 

The  cholesterol  content  of  the  blood  should  be  estimated 
as  a  dift"erential  test  between  cholelithiasis  or  cholecystitis 
with  adhesions  to  the  stomach  or  duodenum,  simulating 
obstructing  duodenal  ulcers ;  likewise,  in  doubtful  cases,  an 
estimation  of  the  efliciency  of  the  pancreatic  ferments  should 
be  made,  both  in  the  aspirated  duodenal  contents  and  in  the 
stools ;    and    in    all    cases    in    which    a    syphilitic    history    is 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  693 

obtained  a  Wassermann  reaction  should  be  carried  out,  and, 
if  positive,  energetic  antiluetic  measures  should  be  begun  and 
continued  for  a  reasonable  length  of  time  before  operative 
procedures  are  considered.  Naturally,  all  of  these  special 
tests  should  be  preceded  by  a  careful  anamnesis,  and  a 
complete  physical  examination,  including  blood-counts  and 
urinalyses. 

In  cases  that  are  diagnostically  so  clear,  such  as  those 
with  a  history  of  a  profuse  hematemesis  (w^here  esophageal 
varices  can  be  excluded),  or  a  massive  melenic  stool,  one  may 
not  have  to  resort  to  these  finer  differential  tests,  but  may 
proceed  at  once  to  treatment.  In  the  more  complicated  cases, 
how^ever,  the  urgency  of  the  case  is  usually  not  so  great  but 
that  a  few  days  may  be  spent  profitably  in  the  carrying  out 
of  these  differential  investigations  without  detriment  to  the 
patient.  With  the  exceptions  of  carcinomatous  degeneration 
of  a  gastric  ulcer;  of  pyloric  obstruction  due  to  cicatricial 
stenosis ;  of  hour-glass  constriction,  sufficient  to  cause  marked 
disturbance  of  gastric  motility;  of  perigastric  abscess,  or  of 
acute  or  chronic  perforation,  ulcer  of  the  stomach  or  duode- 
num is  a  disease  which  lends  itself  to  medical  management 
in  a  majority  of  cases.  But  the  medical  treatment  must 
be  well)  directed,' rigorous,  long  continued,  and  the  best  results 
are  to  be  obtained  where  the  patient  is  under  hospital  super- 
vision ;  and  in  a  hospital  where  there  is  cordial  co-operation 
between  the  attending  physician,  the  diet  kitchen  and  the 
laboratory.  If  the  case  cannot  be  admitted  to  hospital  con- 
trol, treatment  may  be  instituted  at  home,  provided  that  the 
patient  is  attended  by  a  competent  trained  nurse.  The  med- 
ical treatment  of  ambulatory  cases  is  unsatisfactory  to  a 
degree,  so  far  as  ultimate  cure  is  concerned,  although  sup- 
pression or  amelioration  of  symptoms  can  usually  be  secured. 
This  is  strikingly  seen  in  the  dispensary  groups  of  patients. 

There  are  three  essential  features  in  the  medical  manage- 
ment :  complete  bed-rest,  proper  use  of  diets,  and  the  admin- 
istration of  chemical  therapy,  notably  the  antacids  and  the 
antispasmodics. 

The  duration  of  medical  treatment,  of  necessity  indefinite, 
bears  a  somewhat  direct  ratio  to  the  length  of  time  the  ulcer 
has  been  present.     Acute  superficial  phagodenic  ulcers,  such 


694  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

as  are  common  to  chlorosis,  will  usually  heal  in  from  three  to 
six  weeks'  time,  unless  tissue  repair  has  been  diminished. 
Ulcers  that  have  existed  for  a  year  or  more,  and  have  become 
chronic,  in  pathology  as  well  as  symptoms,  may  require  sev- 
eral months  of  active  treatment,  with  a  careful  following  up 
for  two  or  three  years  before  a  definite  cure  can  be  rightfully 
claimed.  Some  ulcers  have  become  so  surrounded  by  con- 
nective-tissue overgrowth,  with  indurated  cicatricial  edges, 
that  their  ven,-  devascularity  prevents  their  ultimately  heal- 
ing. Such  cases  can  only  be  cured  by  excision  of  the  ulcer- 
bearing  area,  and  this  excision  should  be  a  wide  one,  as 
this  type  of  ulcer  is  the  one  most  likely  to  become  cancer 
ultimately. 

Before  undertaking  the  medical  management  of  ulcer  cases 
there  should  be  established  a  thorough  co-operation  between 
the  patient  and  the  doctor,  and  it  is  important  that  the  length 
of  complete  bed-rest  should  be  left  an  indefinite  matter. 
AAhether  this  ^vill  require  three  weeks  or  three  months  can- 
not be  determined  beforehand,  and  the  patient  will  therefore 
be  spared  mam-  disappointments  and  the  doctor  manj^  fruit- 
less arguments  if  this  plan  is  adopted.  The  room  chosen 
should  be  light,  well  ventilated,  and  as  free  from  outside 
noises  as  possible.  The  bed  should  be  of  the  usual  high  hos- 
pital type,  and  with  a  fairh-  hard  mattress.  After  the  patient 
has  once  been  gotten  to  bed,  bed-rest  should  thereafter  be 
complete  and  absolute,  even  to  the  performance  of  all  toilets, 
and  the  patient  should  rest  in  the  recumbent  posture  with 
one,  or  at  the  most  two,  low  pillows  for  at  least  the  first  tAvo 
wrecks,  after  which  the  partly  sitting  posture  may  be  allowed. 

If  the  ulcer  should  be  complicated  by  a  relative  pyloric 
obstruction,  due  to  a  ptotic  stomach  with  an  angulated 
duodenum,  and  especially  if  further  complicated  by  hyper- 
secretion, more  prompt  emptying  of  the  stomach  may  be 
secured  if  the  foot  of  the  bed  is  elevated  10  or  12  inches, 
and  the  patient  is  made  to  assume  the  right,  or,  preferably, 
the  left,  lateral  abdominal  position.  In  certain  cases  this  may 
be  reinforced  by  placing  a  small  circular  pillow,  of  the  bolster 
type,  at  a  point  level  with  the  greater  curvature  of  the 
stomach,  or  proper  supporting  abdominal  pads  may  be  used 
for  this  purpose. 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  695 

GENERAL    HYGIENE. 

Care  of  the  Mouth. — Particular  emphasis  is  to  be  laid 
upon  bringing  the  oral  cavity  and  its  contents  to  as  high  a 
degree  of  cleanliness  as  is  possible.  There  is  a  very  close 
association  between  various  degrees  of  oral  sepsis  and  the 
different  diseases  of  the  stomach,  notably  gastritis,  ulcer  and 
cancer,  and  a  close  inspection  of  the  mouth  should  be  made 
in  patients  about  to  be  given  treatment,  and  in  those  cases 
needing  it  diseased  roots  should  be  extracted,  cavities  filled, 
and  pus  pockets  cleansed  and  evacuated  by  an  expert  dentist 
before  beginning  active  treatment  for  the  ulcer  cure.  A  few 
days  consumed  in  this  way  will  be  of  inestimable  advantage 
later  on.  In  all  cases  the  teeth  should  be  properly  brushed 
three  times  a  day  with  any  good  tooth-paste,  if  there  be  any 
tendency  to  pyorrhea,  and  this  should  be  followed  by  the 
thorough  rinsing  of  the  mouth  and  gargling  of  the  throat 
with  any  one  of  several  mild  antiseptics,  such  as  the  liquor 
antisepticus  alkalinus.  To  insure  oral  asepsis,  it  is  helpful 
to  keep  a  tumbler  of  such  a  solution,  properly  diluted,  by 
the  bedside  of  the  patient,  and  to  encourage  its  frequent 
use.  Gums  that  are  definitely  infected  should  be  swabbed 
daily  with  diluted  tincture  of  iodin,  and  pus  pockets  should 
be  wiped  out  with  either  iodin  or  hydrogen  peroxid, 
or  with  a  solution  of  hydronaphthol,  5  grains  to  the  ounce 
(0.32  Gm.  to  30  mils)  of  equal  parts  of  75  per  cent,  alcohol 
and  distilled  water.  This  may  be  done  once  or  twice  a  day. 
If  amebae  can  be  demonstrated  in  the  pus  pockets,  one  may 
use  emetin  in  ^-grain  (0.015  Gm.)  doses,  dissolved  in  1 
dram  (4  mils)  of  water,  and  by  means  of  a  blunt  needle 
injected  directly  into  the  pus  pockets  every  day  for  four  or 
five  days,  or  they  may  be  swabbed  out  with  a  weak  solution 
of  ipecac,  15  grains  to  the  ounce  (1  Gm.  to  30  mils).  If  spiro- 
chetae  or  spirillse  can  be  demonstrated  in  pus  pockets  they 
should  be  flushed  out  with  a  solution  of  salvarsan,  1^4  grain 
(0.075  Gm.)  dissolved  in  ^  ounce  (15  mils)  of  normal  saline 
solution.  After  the  active  infection  and  the  inflammatory 
residue  have  subsided  it  is  useful  to  massage  the  gums  digi- 
tally, to  re-establish  the  circulation  of  the  gums  and  to 
promote  healing.     Especially  is  this  care  of  the  mouth  indis- 


696  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

pensable  in  those  cases  to  be  treated  either  by  the  preliminary 
starv'ation  method  or  by  duodenal  feeding,  in  order  to  mini- 
mize the  danger  of  parotitis.  Suckling  a  rubber  nursing- 
nipple,  as  recommended  by  Fenwick,ii  or  chewing  gum  as- 
recommended  by  Ochsner,i2  stimulates  the  flow  of  saliva, 
cleanses  the  ducts,  and  guards  against  an  ascending  infection 
of  the  parotid  gland.  The  nipple  should  be  kept  in  95  per  cent, 
alcohol  when  not  in  use. 

Likewise,  infected  tonsils  should  receive  appropriate  treat- 
ment. Those  cases  which  give  a  history  of  recurrent  ton- 
sillitis, with  or  without  rheumatism  or  cardiac  disturbance, 
and  whose  tonsils  are  notably  diseased  and  are  no  longer 
capable  of  a  protective  function,  should  have  a  tonsillectomy 
done  before  the  ulcer  cure  is  actively  begun.  Alilder  grades 
of  tonsillar  infection  should  be  locally  attacked  by  antiseptic 
gargles  and  swabbing  the  tonsils  with  a  silver  solution  in  a 
strength  of  10  per  cent,  to  25  per  cent. 

Where  oral  feeding  is  withheld,  and  the  tongue  becomes 
furred,  thickened,  edematous  or  dry,  it  will  be  found  useful 
to  swab  the  tongue  and  oral  mucous  membranes  with  the 
following  solution :  One  ounce  (30  mils)  of  glycerin  and  the 
juice  of  one  lemon.  Also,  when  indicated,  appropriate  local 
treatment  should  be  given  the  nasal  passages. 

Care  of  the  Body.  Each  morning  there  should  be  given 
a  cleansing  bath,  either  hot  or  tepid,  always  to  be  followed  by 
a  cold  sponge,  unless  contraindicated,  and  this  by  an  alcohol 
rub,  and  the  body  sprinkled  w-ith  a  talcum  powder  containing 
stearate  of  zinc.  The  cold  sponge  may  be  repeated  again  at 
night,  if  desired,  and  will  prove  helpful  in  inducing  sleep ; 
invariably  it  should  be  followed  by  the  alcohol  rub  and  the 
use  of  the  powder. 

In  those  cases  who  are  undernourished,  due  to  inanition, 
or  in  those  where  the  skin  is  dry  and  scaly,  a  daily  inunction 
of  olive  oil  may  be  used.  In  patients  who  are  much  ema- 
ciated, or  who  show  a  tendency  to  bed-sore  formation,  the 
use  of  any  of  the  various  protective  pressure  rings  or  air 
pillows  is  indicated. 

It  is  important  to  mention  the  usefulness  of  proper  breath- 
ing exercises  to  increase  the  oxygenation  of  the  blood,  which 
the  writer  believes  has  a  decided  tendency  to  promote  healing 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  697 

of  internal  ulcerated  areas.  It  will  be  of  service  to  have  the 
patient  hold  between  the  lips  a  quill  toothpick  whose  pointed 
ends  have  been  cut  away,  or  any  other  suitable  hollow  tube 
of  small  caliber,  and  through  this  to  take  20  to  30  deep 
inhalations  and  exhalations  two  or  three  times  a  day,  either 
from  an  oxygen  tank  or  by  wheeling  the  bed  near  an  open 
window. 

Local  Applications  of  Heat  or  Cold  to  the  Abdomen.  All 
cases,  except  those  in  which  there  has  been  a  history  of  recent 
bleeding  from  the  gastro-intestinal  tract,  should  be  treated  by 
hot  compresses,  continuously  applied  for  the  first  week  to  ten 
days  of  treatment.  These  hot  compresses  should  be  made  of 
flannel  folded  into  three  or  four  thicknesses,  or  of  spongiolin, 
either  of  which  are  to  be  cut  to  a  size  that  will  cover  the 
entire  abdominal  surface  from  the  xiphoid  to  the  pubic  bone, 
and  should  be  wrung  out  of  water  as  hot  as  can  be  borne. 
The  compress  should  be  covered  by  a  layer  of  oiled  silk  and 
a  snugly  fitted  abdominal  binder,  and  both  should  be  carried 
1  to  2  inches  (2.54  to  5.08  cm.)  above  and  below  the  com- 
press to  prevent  evaporation  or  cooling  by  outside  currents 
of  air.  The  abdominal  binder  should  then  be  covered,  pre- 
ferably by  an  electric  warm  pad,  or  a  partly  filled  hot-water 
bottle.  These  hot  compresses  should  be  changed  every  hour 
during  the  day  and  once  or  twice  during  the  night.  This  use 
of  moist  heat  will  be  found  of  great  service  for  the  relief  of 
pain,  and  in  allaying  perigastric  or  duodenal  inflammation, 
or  a  localized  peritonitis,  and  may  even  have  a  tendency 
to  soften  and  separate  recent  perigastric  adhesions.  Where 
there  is  sufficient  inflammatory  perigastric  exudate  to  cause 
a  palpable  tumor,  especially  in  the  presence  of  a  leukocytosis, 
hot  flaxseed  poultices  should  be  made  to  alternate  with  the 
hot  compresses,  and  changed  hourly,  or  every  half-hour,  until 
improvement  is  noted.  Before  beginning  the  use  of  these  hot 
applications,  it  is  well  to  sterilize  the  skin  to  avoid  any  pos- 
sibility of  infection  from  blister  formation.  For  this  purpose 
the  writer  prefers  the  solution  recently  recommended  by 
A.  D.  Whiting.i^  After  extensive  tests  it  has  shown  the  high- 
est efficiency.  The  formula  consists  of  acetone,  35  mils ; 
phenoco,  2  mils;  alcohol  (95  per  cent.),  q.  s.  ad  100  mils. 
Ru-b  the  skin  for  two  minutes  with  a  piece  of  gauze  saturated 


698  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

with  the  solution.     The  sterilization  should  be  repeatea  on 
the  second  and  third  day  and  then  discontinued. 

Where  there  has  been  a  history  of  recent  gastro-intestinal 
hemorrhage  within  from  six  weeks  to  two  months  before 
beginning  treatment,  or  where  occult  blood  can  be  demon- 
strated in  the  stools,  the  use  of  hot  compresses  is  contraindi- 
cated,  and  extreme  degrees  of  cold  are  to  be  substituted,  in 
the  form  of  constant  applications  of  ice-bags,  particularly  to 
the  epigastrium,  or  the  use  of  ice-water  coils  in  hospitals 
suitably  equipped.  The  use  of  cold,  rather  than  heat,  should 
be  continued  for  one  week,  or  until  all  traces  of  altered  blood 
have  disappeared  from  the  stools,  when  the  use  of  hot  com- 
presses should  be  begun  as  outlined  above. 

When  there  has  been  recent  hemorrhage,  no  food  or  drink 
should  be  allowed  by  mouth  until  all  occult  blood  has  disap- 
peared from  the  stools. 

Everything  should  be  done  to  insure  complete  mental  and 
physical  relaxation,  to  protect  the  stomach  from  insult, 
mechanical,  chemical  and  thermal,  to  provide  sufficient  nour- 
ishment to  keep  up  the  bodily  vigor  of  the  patient,  to  prevent 
undue  immediate'  loss  of  weight,  and  later  to  promote  a  gain 
in  weight. 

Foods  should  be  bland,  furnished  in  a  proper  form,  and  in 
only  sufficient  amounts  at  any  one  time  as  will  not  encourage 
mechanical  overactivity  of  the  stomach  or  exert  a  drag  on  its 
supporting  ligaments.  As  a  rule,  it  is  wise  to  insist  upon 
total  food  abstinence  by  mouth  in  all  cases,  and  certainly  in 
those  of  the  bleeding  type,  for  a  period  of  from  three  to  seven 
days,  the  time  usually  averaging  five  days.  During  this 
period  especial  attention  is  to  be  directed  to  the  care  of  the 
mouth,  as  outlined  above. 

The  most  disagreeable  subjective  feature  during  this  time 
is  a  somewhat  excessive  thirst.  This  is  to  be  controlled  by 
cleansing  the  mouth  and  by  sucking  cracked  ice,  care  being 
taken  not  to  swallow  any.  The  chewing  of  gum,  as  pointed 
out  by  Ochsner,  helps  to  relieve  thirst.  The  saliva  may  be 
swallowed.  In  addition,  the  administration  of  various  liquids 
by  rectum  is  indicated.  In  the  writer's  opinion  the  best  is  a 
decinormal  solution  of  soda  bicarbonate,  rather  than  decinor- 
mal  salt  solution,  inasmuch  as  it  has  a  tendency  to  combat 


ULCER  Ul'"  THE  STOMACH  AND  DUODENUM.  699 

an  acidosis  arising  from  starvation.  Stronger  concentrations 
of  soda  bicarbonate  are  not  necessary;  they  may  be  unduly 
irritating,  and  have  a  tendency  to  cause  increased  intestinal 
peristalsis,  which  is  something  to  be  avoided.  It  may  be  per- 
missible to  add  to  the  decinormal  soda  bicarbonate  solution 
sufficient  glucose  in  percentages  ranging  from  three  to  five, 
remembering,  however,  that  sugar  and  albuminous  substances 
tend  to  promote  putrefaction  in  the  bowels.  It  is  best  to 
administer  this  solution  by  the  Murphy  method,  adjusting  the 
rate  of  the  drops  so  that  about  500  mils  (16.67  oz.)  can  be 
introduced  in  an  hour.  Should  this  rate  of  flow  cause  discom- 
fort, it  should  be  decreased  to  the  point  of  easy  tolerance. 
The  rectal  tube  should  not  be  introduced  farther  than  from 
3  to  5  inches  (7.62  to  12.70  cm.).  As  a  rule,  it  is  not  neces- 
sary to  give  more  than  a  total  of  2000  to  2500  mils  (66.67  to 
83.84  oz.)  of  this  solution  in  twenty-four  hours.  In  the  event 
of  hemorrhoids,  they  should  be  treated  by  cold  compresses 
soaked  in  the  fluidextract  of  hamamelidis,  and  internal  hemor- 
rhoids by  the  application  of  a  5  per  cent,  ointment  of  extract 
of  hamamelidis  with  equal  parts  of  lanolin  and  petrolatum, 
introduced  by  means  of  a  hemorrhoidal  syringe.  This  treat- 
ment should  follow  the  enteroclysis  and  the  use  of  rectal 
alimentation. 

Nutritive  Enemas.  It  is  the  custom  of  many  to  make  use 
of  nutritive  rectal  enemata  during  the  period  of  all  food 
abstinence,  but  it  is  doubtful  whether  this  is  actually  neces- 
sary as  a  supportive  measure,  and  in  the  writer's  experience 
it  frequently  causes  so  much  discomfort  to  the  patient  as  to 
neutralize  its  possible  beneficial  efifect.  There  are  many 
standard  nutritive  enemas  to  which  reference  is  made  in  the 
monographs  on  the  subject,  but  the  writer  has  had  most  sat- 
isfaction from  the  following  formula:  Milk  200  mils  (66.67 
ozs.),  the  yolk  of  one  ^%%,  milk-sugar  15  grammes  (231.45 
grs.),  to  which  is  added  a  pinch  of  salt.  This  should  be  thor- 
oughly stirred  and  peptonized  for  ten  minutes  by  adding  the 
contents  ©^f  one  of  the  tubes  of  Armour's  or  Fairchild's  pan- 
creatic powder;  after  this  the  mixture  should  be  injected  very 
slowly  at  a  temperature  of  110°,  and  with  the  patient's  hips 
slightly  elevated.  If  the  rectum  is  irritable,  a  few  drops  of 
the  tincture  of  opium  or  of  the  deodorized  tincture  of  opium 


700  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

may  be  added  to  the  enema,  three  or  four  of  which  may  be 
given  during  the  course  of  twenty-four  hours. 

General  Medicinal  Management.  Except  as  needed  to 
control  urgent  symptoms,  the  use  of  chemical  therapy  does 
not  have  anything  like  the  importance  in  the  medical  cure  of 
ulcer  as  does  complete  bodily  and  mental  rest,  proper  feeding, 
and  external  applications  to  the  abdomen.  The  use  of  drugs 
should  be  zvithheld,  unless  their  use  is  definitely  indicated. 

The  writer  knows  of  only  three  drugs  which  may  directly 
aid  in  the  healing  of  an  ulcer.  In  an  acute  ulcer,  without 
indurated  edges,  the  use  of  bismuth  acts  not  only  as  a  mild 
antacid,  but  serves  to  coat  over  the  floor  of  the  ulcer  and 
partly  to  protect  it  from  the  corrosive  action  of  the  gastric 
juice,  and  irritation  from  food  particles. 

Where  bismuth  is  used  the  subcarbonate  is  the  best  form, 
and  may  be  given  in  doses  of  from  10  to  20  grains  (0.65  to 
1.3  Gm.)  e.very  two  to  four  hours.  The  subnitrate  of  bismuth 
should  not  be  used  on  account  of  the  danger  of  mechanical 
irritation  by  its  sharp  crystals. 

In  the  chronic,  sluggish,  indolent  ulcer  the  use  of  silver 
nitrate  ma}^  serve  to  stimulate-  the  formation  of  granulation 
tissue,  and  to  promote  healing.  Certainly,  it  can  be  said  that 
in  ambulatory  cases  of  ulcer  of  this  type  subjective  improve- 
ment is  seen  by  the  use  of  lavage  with  a  solution  of  silver 
nitrate  of  a  strength  beginning  with  1:5000,  and  gradually 
increasing  to  a  strength  of  1 :  1000.  Where  silver  nitrate  is 
given  orally,  the  writer  prefers  to  employ  the  nine-day  cycle 
suggested  by  Lockwood  and  described  on  page  708. 

The  third  drug  of  essential  ser^nce  is  belladonna,  or  its 
alkaloid  atropin.  Its  usefulness  lies  in  the  fact  that  it  most 
effectively  controls  gastric  secretion  and  lessens  its  concen- 
tration, and,  furthermore,  it  retards  hyperperistalsis  and 
diminishes  gastric  motility.  The  rationale  of  its  use  is  there- 
fore plain,  and,  besides,  it  is  well  tolerated.  It  should  be 
administered  in  the  form  of  the  tincture  of  belladonna,  given 
every  four  hours,  beginning  with  5  minims  (0.30  Gm.),  and 
increasing  1  minim  (.06  Gm.)  each  time  taken,  until  a  definite 
physiologic  effect  is  produced,  namely,  a  dilatation  of  the 
pupils,  with  blurring  of  vision,  and  a  dryness  of  the  mouth 
and  fauces.     When  this  point  is  reached,  which  will  usually 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  701 

occur  with  a  dosage  of  15  minims  (1  mil),  the  drug  should 
be  discontinued  for  one  or  two  doses,  and  then  be  continued 
in  a  constant  dosage  of  3  to  5  minims  (0.1  to  0.3  mil)  less 
than  the  dose  producing  physiologic  effect,  and  maintained  at 
this  point  for  two  or  three  weeks. 

Where  there  is  hypersecretion  or  hyperacidity,  the  use  of 
alkalies  becomes  absolutely  necessary.  In  addition  to  bis- 
muth and  belladonna,  the  following  drugs  may  be  recom- 
mended :  magnesia  usta  (the  oxide  of  magnesia)  and  sodium 
bicarbonate.  These  may  be  combined  in  powder  form  with 
bismuth  subcarbonate  in  equal  parts,  in  a  dosage  of  10  to  20 
grains  (0.6  to  1.2  Gm.)  given  every  two  to  four  hours,  sus- 
pended in  water. 

Bolton^*  urges  the  use  of  lime-water  in  place  of  soda 
bicarbonate,  because  the  latter,  in  neutralizing  hydrochloric 
acid,  does  so  with  the  liberation  of  carbon  dioxide  gas,  which 
distends  the  stomach  unless  promptly  eructated.  Further- 
more, Bolton  believes  that  lime-water  does  not  excite  gastric 
secretion.  He  gives  lime-water  in  teaspoonful  doses  about 
midway  between  each  feeding. 

Working  on  the  hypothesis  that  hyperacidity  is  one  of  the 
potent  influences  in  retarding  the  healing  of  an  ulcer,  Sippy 
has  recommended  the  following  plan  of  administering  alka- 
lies. He  enjoins  absolute  bed-rest,  and  for  five  days  with- 
holds all  food  and  drink  by  mouth,  and  begins  hourly  feedings 
on"  the  morning  of  the  sixth  day.  Each  morning,  one-half 
hour  before  the  first  feeding,  he  gives  1  teaspoonful  (3.75 
Gms.)  of  bismuth  subnitrate,  suspended  in  one-half  glass  of 
water,  and  midway  between  each  feeding  he  gives,  alternately, 
a  powder  suspended  in  1  ounce  (30  mils)  of  water,  consisting 
of  calcined  magnesia  10  grains  (0.6  Gm.)  and  sodium  bicar- 
bonate 10  grains  (0.6  Gm.),  and  a  second  powder  of  bismuth 
subnitrate  10  grains  (0.6  Gm.)  and  sodium  bicarbonate  10 
grains  (0.6  Gm.).  Thus  the  patient  receives  20  grains  (1.2 
Gm.)  of  an  antacid  powder  every  hour,  midway  between 
feedings.  If  the  powder  containing-  magnesia  produces  diar- 
rhea, this  is  to  be  prevented  or  controlled  by  substituting  the 
powder  containing  bismuth  a  sufficient  number  of  times  to 
control  it,  and,  conversely,  if  constipation  ensues,  the  mag- 
nesia and  soda  powder  should  be  given  more  frequently. 


702  DISEASES   OF    THE    DIGESTIVE   SYSTEM. 

After  the  fourth  or  fifth  week,  as  the  amount  of  food 
is  increased  and  the  time  interval  lengthened,  the  pow- 
ders are  still  to  be  given  midway  between  the  feedings, 
but  "the  quantity  taken  each  time  may  be  proportionately 
increased. '"15 

Sippy  continues  the  use  of  the  morning  bismuth,  in 
teaspoonful  doses,  for  six  or  eig"ht  weeks,  and  continues 
the  use  of  the  other  powders,  midw-ay  between  the  feed- 
ings, for  three  or  four  months  if  the  ulcer  is  a  recent  one, 
and  intermittently  for  several  months  longer  if  the  ulcer  is  of 
long  duration. 

As  a  routine  procedure  in  all  cases  of  ulcer,  this  method 
may  be  open  to  criticism,  and  should  be  reserved  for  those 
cases  of  proved  hyperacidity^  with  or  without  symptoms,  and, 
if  adopted,  the  writer  prefers  the  use  of  the  subcarbonate  of 
bismuth  to  that  of  the  subnitrate,  for  the  reasons  stated  above, 
(See  p.  701.) 

Of  other  alkalies,  Carlsbad  water  has  long  enjoyed  the 
reputation  of  being  a  truly  medicinal  agent  in  the  cure  of 
ulcer.  This  view  is  particularh-  held  by  European  clinicians, 
and  is  especially  endorsed  by  von  Leube.  It  is  particularly 
useful  in  the  constipated  cases,  and  may  be  given  in  ^-  to  1- 
glassful  doses,  once  or  twice  a  day  on  a  fasting  stomach.  It 
is  not  always  possible  to  obtain  the  original  Carlsbad  water, 
and  the  desiccated  salts  may  be  substituted  in  a  dosage  of  15 
grains  (1  Gm.)  to  a  glassful  of  w^ater.  Probabl}^  the  artificial 
Carlsbad  salts,  the  sal  carolinnm  factitiiim  of  our  pharmaco- 
poeia, are  equally  good,  easier  to  obtain,  and  cheaper.  The 
dosag-e  should  be  1  teaspoonful  (3.75  mils)  of  the  salts  in  a 
glassful  of  water  once  or  twice  daily. 

Man}^  other  alkaline  waters  may  serve  a  similar  purpose, 
and  the  writer  particularly  likes  to  make  use  of  Celestins 
Vichy,  and  especially  during  the  later  w'eeks  of  the  illness, 
and  in  the  follow-up  plan  of  treatment. 

Paul  Cohnheim  is  an  enthusiastic  indorser  of  the  use  of 
olive  oil.  He  recommends  the  use  of  2  to  4  drams  (7.S  to 
15  mils)  of  pure  olive  oil.  three  or  four  times  a  dav  before 
feedings,  in  those  cases  exhibiting  the  pain  of  pylorospasm, 
and  the  use  of  an  oil  emulsion,  1  teaspoonful  (3.75  mils),  of 
either  olive  or  almond  oil,  the  yolk  of  one  egg,  and  water  to 


ULCER  OF  TI-IE  STOMACH  AND  DUODENUM.  703 

make  3  ounces  (90  mils),  to  be  used  in  cases  without  pyloro- 
spasm.  The  writer  believes  that  the  use  of  oil  does  not  facili- 
tate the  healing  of  an  ulcer,  and  confines  its  use  to  such 
ambulatory  cases  as  will  neither  submit  to  a  thorough  med- 
ical regime,  nor  consent  to  operative  interference. 

Diet.  The  essential  features  of  the  diet  are  threefold:  (1) 
to  provide  sufficient  nourishment;  (2)  to  be  of  small  bulk 
and  of  a  bland,  non-irritating  type ;  and  (3)  to  counteract  or 
control  hyperacidity.  This  last  is  an  especially  important 
essential. 

For  many  years  only  two  methods  of  feeding  were  advo- 
cated in  ulcer  cases,  that  of  von  Leube  and  that  of  Lenhartz, 
and  between  the  two  a  controversy  existed  which  continued 
for  years,  and  which  has  been  kept  alive  by  the  different  fol- 
lowers of  these  gastric  clinicians,  first  in  Europe  and  later  in 
this  country.  These  two  methods  differ  rather  widely  one 
from  the  other,  but  that  of  von  Leube  has  proved  more 
acceptable  to  the  general  clinician.  The  character  of  this 
article  does  not  permit  of  an  extensive  review  of  these  two 
methods,  which  are  quoted  in  detail  in  many  monographs,  but 
they  differ  essentially  in  these  points :  the  von  Leube  methdd 
consists!  in  withholding  all  food  by  mouth,  in  all  cases,  for  a 
_period  of  three  days,  with  the  patient  under  complete  bed-rest 
for  ten  days,  and  then  proceeding  to  the  use  of  increasing 
amounts  of  food  each  day.  The  diet  is  of  a  type  that  is  bland 
and  non-irritating,  and  largely  composed  of  carbohydrates, 
which  tend  to  diminish  both  the  amount  and  concentration  of 
the  gastric  juice.  By  the  Lenhartz  method  one  proceeds  to 
feed  the  patient  at  once,  even  in  the  face  of  hemorrhage,  using 
repeated  small  feedings  of  a  variety  of  highly  albuminous 
foods,  selected  for  their  ability  to  combine  with  the  free 
hydrochloric  acid  of  the  gastric  juice  so'  as  to  form  a  loosely 
combined  acid  albumin,  which  Lenhartz  believes  prevents 
further  erosion  and  facilitates  healing.  He  maintains  that  the 
recuperative  forces  of  the  patient  are  depleted  by  the  under- 
feeding of  von  Leube's  method,  and  that  the  tendency  of  the 
ulcer  to  heal  is  thereby  retarded. 

It  is  by  no  means  necessary  strictly  to  adopt  either  one  of 
these  two  methods  in  the  exact  detail  of  its  originator,  nor 
does  the  writer  believe  that  every   case   can   be   religiously 


704  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

treated  by  the  same  dietetic  method.*  As  a  general  rule,  the 
principle  of  placing^  the  stomach  in  a  state  of  complete  phys- 
iologic rest  for  a  few  days  is  a  sound  one,  and  this  can  best 
be  accomplished  by  abstaining  from  all  food  by  mouth  for 
three,  or  not  more  than  five,  days.  Yet  the  use  of  rectal 
enemata,  and  in  certain  cases  even  the  use  of  proctoclysis, 
excites  intestinal  peristalsis,  which,  in  turn,  may  reflexly  pro- 
duce pylorospasm  and  gastric  peristalsis,  and  thus  increase 
the  difficulty  of  securing  physiologic  rest.  Again,  there  are 
some  profoundly  cachetic  patients  in  whom  it  may  be  expe- 
dient to  begin  feedings  at  once,  barring  recent  hematemesis. 
In  such  instances,  rather  than  run  the  risk  of  undermining 
further  the  patient's  vigor  and  recuperative  power  by  total 
food  abstention  for  even  two  or  three  days  longer,  it  seems 
better  to  dispense  with  the  preliminary  fast. 

In  all  cases  the  writer  proceeds  to  feed  at  once,  using  a 
formula  personally  communicated  to  him  by  Joseph  Sailer, 
and  as  yet  unpublished.  This  formula  consists  of  cream, 
whites  of  eggs,  lactose  and  rice-water.  The  caloric  strength 
of  this  mixture  can  be  readily  augmented  by  gradually  increas- 
ing the'  amounts  of  the  first  two  ingredients,  and  by  adding 
later  the  yolks  of  eggs.  This  formula  is  bland  and  rich  in  al- 
bumin, and  the  writer  has  yet  to  see  a  case  in  which  it  is  not 
easily  tolerated  by  even  the  most  sensitive  stomachs.  For  the 
first  day's  feeding  it  is  well  to  begin  with  the  following :  cream, 
2  ounces  (60  mils);  white  of  1  egg;  lactose,  1  ounce  (30 
Gms.),  and  rice-water  sufficient  to  make  1  pint  (473.11  mils). 
The  rice-water  is  to  be  made  by  thoroughly  boiling  1  ounce 
(30  Gms.)  of  clean  rice  in  a  pint  (473.11  mils)  of  water.  The 
value  of  this  formula  is  approximately  300  calories.  This,  a 
rather  flat,  tasteless  mixture,  may  be  made  more  palatable  by 
the  addition  of  4  ounces  (120  mils)  of  chocolate  or  cocoa,  pre- 
pared in  the  usual  manner,  or  an  equal  quantity  of  black 
coffee;   or  sufficient   grape-juice   may  be   added   to   make   it 


*  The  reader  is  referred  to  a  recently  published  article  by  Smithies 
(Smithies:  Am.  Jour.  Med.  Sc,  1917,  cliii),  who  calls  attention  to  the 
good  results  he  has  obtained  in  the  treatment  of  gastric  ulcer  by  a  carbo- 
hydrate diet  and  abstaining  as  much  as  possible  from  the  use  of  antacid 
medication.  This  paper  appeared  too  late  to  be  incorporated  in  this 
chapter. 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  705 

palatable.  This  mixture  should  be  bottled  and  packed  in  ice, 
and  should  be  served  very  cold,  beginning  with  2  ounces  (60 
mils)  every  hour  from  7  a.m.  until  7  p.m.  Patients  should  not 
be  disturbed  for  feeding  at  night  more  than  once  or  twice,  and 
the  food  should  be  given  at  the  same  time  that  the  hot  com- 
press applied  to  the  abdomen  is  changed.  The  total  caloric 
value  for  this  first  day  will  be  approximately  500.  This 
formula  feeding  should  be  continued  for  the  first  seven  days. 

In  feeding  all  liquid  foods  that  are  to  be  served  cold,  it 
adds  much  to  the  comfort  of  the  patient  and  the  acceptabilit}^ 
of  the  food,  if  care  is  taken  to  have  it  attractively  served  and 
ice-cold.  The  2-,  4-  or  6-  ounce  (60,  120  or  180  mils)  glass, 
according  to  the  amount  of  each  feeding,  should  be  of  a  thin 
glassware,  and  placed  in  the  center  of  a  deep  bowl,  such  as 
a  finger-bowl,  packed  with  crushed  ice ;  the  spoon,  also,  should 
be  kept  well  iced. 

If  there  is  no  discomfort  arising  from  this  first  day's  feed- 
ing, on  the  second  day  the  formula  may  be  strengthened  by 
doubling  the  amount  of  cream  and  egg  albumin  and  feeding 
in  2-ounce  (60  mils)  doses,  every  hour  from  7  a.m.  until  7 
P.M.,  and  one  or  two  feedings  at  night.  This  will  represent 
approximately  900  calories. 

The  third  day  the  formula  may  be  strengthened  by  using 
2  whole  eggs,  whites  and  yolks  instead  of  the  whites  alone, 
and  the  feedings  may  be  increased  to  3  ounces  (90  mils)  every 
hour  from  7  a.m.  until  7  p.m.,  with  one  or  two  feedings  at 
night.  This  will  approximate  1500  calories.  Feedings  should 
only  be  increased  from  2  to  3  ounces  (60  to  90  mils)  in 
amount,  provided  there  has  been  no  discomfort  from  the 
second  day's  feeding.  As  a  rule,  under  this  dietetic  regime 
all  pain  and  gastric  discomfort  promptly  subside.  Occasion- 
ally, however,  even  this  amount  of  food  produces  an  increase 
of  gastric  tension,  or  the  painful  sensation  of  pylorospasm. 
In  such  an  event,  it  is  well  to  abstain  from  all  foods  by  mouth 
and  to  adopt  the  methods  outlined  above.  In  any  case  it  is 
advisable,  however,  to  give  proctoclysis  to  the  extent  of 
2  quarts  (2  1.)  of  decinormal  soda  bicarbonate  solution, 
inasmuch  as  this  will  tend  to  combat  the  development  of 
acidosis,  which  may  arise  from  persistent  feeding  "of  a  diet 
rich  in  butter  fats,  a  possibility  to  which  Pritchard  has  drawn 

45 


706  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

attention.  The  hot  compresses  are  to  be  applied  and  changed 
every  hour  during  the  day,  and  once  or  twice  during  the 
night,  as  outlined  above,  during  these  first  seven  days.  The 
bowels  should  be  moved  each  day  with  a  cleansing  enema, 
except  in  those  cases  in  which  the  three-day  starvation  plan 
is  adopted,  when  the  bowels  are  to  be  moved  by  a  cleansing 
enema  the  night  before  beginning  treatment,  but  need  not  be 
moved  again  until  the  third  or  fourth  day.  Should  tympanites 
develop  during  this  first  week,  usuall}^  it  can  be  relieved  by 
substituting  turpentine  stupes  for  the  hot  compresses,  and  by 
using  the  rectal  tube.  Should  this  not  suffice,  hypodermic 
injections  of  eserin  sulphate  in  a  dosage  of  3oO  grain  (0.001 
Gm.)  may  be  given  every  three  hours  for  three  or  four  doses. 
No  drugs  are  to  be  administered  by  mouth,  with  the  possible 
exception  of  soda  bicarbonate,  10  or  20  grains  (0.6  to  1.2 
Gms.)  of  which  may  be  dissolved  in  1  or  2  ounces  (30  to  60 
mils)  of  water,  and  given  ever}^  second  hour  between  the 
feedings.  It  is  usually  wise  to  determine  the  presence  or 
absence  of  free  hydrochloric  acid  in  the  stomach  by  the  use 
of  a  duodenal  catheter,  introduced  between  or  just  before 
feedings.  Should  free  hydrochloric  acid  be  present  in  any 
degree  above  15  acidity  per  cent.,  the  soda  bicarbonate  solu- 
tion may  be  resorted  to;  otherwise  chemical  therapy  should 
be  entirely  withheld,  except  where  it  is  necessary  to  combat 
certain  symptoms,  such  as  pylorospasm,  hyperacidity  or 
hypersecretion,  which  will  be  described  later. 

On  the  fourth  day  the  amount  may  be  increased  to  5 
ounces  (150  mils)  every  two  hours,  with  one  or  two  feedings 
at  night,  and  on  the  sixtli  and  seventh  days  may  be  still  fur- 
ther increased  to  6  ounces  (180  mils)  every  two  hours,  with 
one  or  two  feedings  at  night.  Should  this  formula  in  any 
wise  disagree,  peptonized  milk  may  be  used  alternately  every 
other  feeding  in  the  amounts  scheduled  for  that  day.  This 
will,  however,  somewhat  reduce  the  caloric  value.  Lock- 
wood's^*^  method  of  peptonization  is  an  excellent  one,  and  is 
as  follows : 

"To  1  pint  of  milk  there  should  be  added  ^  pint  of  water, 
and  the  mixture  is  to  be  divided  into  two  equal  parts.  Boil 
one  part,  and  immediatel}'  afterward  add  the  other.  Stir  in 
the  contents  of  a  peptonizing  tube,  and  set  the  bottle  in  warm 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  707 

water  for  one  and  one-quarter  hours.  Bring  rapidly  to  a  boil 
and  keep  on  ice.  The  completely  peptonized  milk  should  have 
a  slightly  bitter,  but  not  unpleasant  taste." 

Treatment  from  the  Eighth  to  the  Fifteenth  Day.  The 
two-hourly  plan  of  feeding  should  be  continued  during  the 
day  with  only  one  feeding  at  night,  which  is  to  be  given  at 
midnight,  but  there  may  be  substituted  for  any  one  of  the 
formula-feedings  one  of  the  following  articles  in  amounts  not 
to  exceed  6  ounces  (180  mils)  :  mammala;  any  cooked  cereal, 
such  as  cream  of  wheat,  farina,  wheatena,  oatmeal  or  arrow- 
root gruel  may  be  eaten  with  cream  and  sugar;  creamed 
macaroni  or  spaghetti,  without  cheese ;  boiled  rice,  milk  toast, 
soft-boiled  egg,  egg-custard,  blanc  mange,  junket,  vanilla  ice- 
cream, wine-jelly  or  calf's-foot-jelly. 

The  eighth  day  only  one  substituted  article  is  to  be  given. 
The  ninth  day  two  may  be  permissible,  and  for  the  balance 
of  the  second  week  three  substitutions  may  be  allowed. 
Every  attempt  should  be  made  to  vary  the  diet  so  as  to  avoid 
monotony,  and  to  cater  especially  to  the  patient's  taste. 

The  external  applications  are  to  be  continued  during  this 
second  week,  but  need  be  changed  only  every  second  hour. 
Should  this  increase  of  diet  during  the  second  week  be  provo- 
cative of  any  symptoms,  such  as  discomfort  due  to  increased 
acidity,  pylorospasm,  or  the  recurrence  of  occult  bleeding,  the 
dietary  should  be  reduced  to  that  of  the  first  week.  The  daily 
cleansing  enema  is  to  be  continued.  In  those  who  are  unduly 
constipated  or  flatulent,  and  especially  in  those  patients  with 
furred  tongues,  undue  drowsiness,  headache  or  other  evidence 
of  hepatic  torpor,  the  use  of  Carlsbad  water  is  indicated,  or 
the  artificial  salts  sal  carolinum  factitium  may  be  substituted, 
using  1  level  teaspoonful  (3.75  Cms.)  dissolved  in  a  glassful 
of  water.  This  should  be  given  cold  to  those  whose  constipa- 
tion is  of  the  atonic  type,  and  hot  to  those  having  spastic  con- 
stipation. Two  or  three  doses  may  be  given  each  day  accord- 
ing to  the  results  obtained.  The  first  dose  should  be  g-iven 
on  an  empty  stomach  one  hour  before  the  daily  feedings  are 
begun.  This,  likewise,  will  tend  to  counteract  any  hyperacid- 
ity. Equally  good  results,  however,  may  be  obtained  by  the 
use  of  magnesia,  either  alone  as  the  milk  of  magnesia  in  tea- 
spoonful  (3.75  mils)  doses  two  or  three  times  a  day,  or  the 


708  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

oxid  of  magnesia,  10  grains  (0.65  Gm.),  to  be  combined  with 
a  like  amount  of  soda  bicarbonate,  and  to  be  dissolved  in  from 
^  to  1  glassful  of  water.  In  those  cases  in  which  pain  per- 
sists, notwithstanding  the  above  measures,  the  use  of  silver 
nitrate,  according  to  the  plan  suggested  by  Lockwood,i"  may 
be  adopted.     He  recommends  the  following  prescription : 

B  Argenti  nitratis  gr.  16  (1.03  Gm.). 

Aqua  destillata Sij    (60  mils). 

M.     Sig. :    Five  minims  equals  gr.  %  (.01  Gm.). 
Give   15  to  25  minims    (0.9  to  1.5  mils)    in   distilled 
water,  thrice  daily,  one-half  hour  before  eating. 

Lockwood  recommends  using  this  in  nine-day  cycles  as 
follows:  The  first  three  days  give  15  minims,  which  equals 
^  grain  (0.0325  Gm.),  three  times  a  day;  the  second  three 
days  give  20  minims  or  ^  grain  (0.04875  Gm.)  three  times  a 
day ;  for  the  next  three  days  give  25  minims  or  %  grain 
(0.05416  Gm.)  three  times  a  day.  Any  resulting  diarrhea 
should  be  met  by  reducing  the  dose  or  entirely  withholding 
it.  Lockwood  states  that  "the  silver  nitrate  cycle  seems  to 
be  indicated  especially  in  those  ulcers,  with  clean  tongues  and 
regular  bowel  functions,  which  are  accompanied  by  a  height- 
ened acidity,  and  usually  with  persistent  pain."  During  this 
first  fourteen  days  absolute  rest  in  bed  should  be  strictly 
enforced. 

Treatment  from  the  Fifteenth  to  the  Twenty-first  Day. 
The  formula  feedings  may  be  reduced  to  two  or  three  a  day, 
taking  8  ounces  (240  mils)  in  the  middle  of  the  forenoon,  the 
middle  of  the  afternoon  and  at  bedtime,  and  the  feeding  dur- 
ing the  night  may  be  discontinued.  In  those  cases  in  which 
milk-foods  are  not  well  borne,  the  formula  feedings  may  be 
discontinued,  and  the  articles  allowed  during  the  second  week 
may  be  increased  by  the  addition  of  cream  soups  or  purees, 
except  those  made  from  meat  or  meat-stock,  which  excite  too 
strongly  the  secretion  of  the  gastric  glands ;  mashed,  creamed 
or  baked  potato,  if  thoroughly  cooked ;  zwiebach  or  crackers, 
which  must  be  thoroughly  masticated.  Creamed  fish  and  all 
vegetables  that  can  be  mashed  and  put  through  a  colander 
and  served  in  a  soft  puree,  such  as  squash,  cauliflower-tips, 
spinach,  turnips,  and  soft  desserts,  as  tapioca,  rice-pudding 
and  floating  island  are  permissible.     Two  or  three  of  these 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  709 

articles  of  diet  may  be  given  at  one  time,  and  the  feedings 
should  be  given  every  three  hours.  During  this  third  week 
the  patient  may  be  allowed  to  rise  for  the  essential  toilets. 
The  external  applications  should  be  continued  according  to 
the  plan  of  the  second  week.  The  bow'els  should  be  kept 
regulated  by  enemas  and  the  use  of  the  Carlsbad  treatment. 
With  the  increase  of  diet  allowed  during  the  third  week,  the 
gastric  secretions  may  be  so  stimulated  as  to  need  the  use  of 
antacids,  such  as  soda  bicarbonate,  magnesia  or  lime-water, 
which  may  be  combined  with  bismuth  subcarbonate  in  a  pow- 
der form,  consisting  of  the  oxide  of  magnesia,  10  grains  (0.6 
Gm.)  ;  bismuth  subcarbonate,  10  grains  (0.6  Gm.)  ;  soda  bicar- 
bonate, 20  grains  (1.2  Gm.).  This  is  to  be  dissolved  or  sus- 
pended in  water,  2  or  3  ounces  (60  or  90  mils),  and  to  be 
taken  one-half  hour  after  meals.  If  there  is  gaseous  disten- 
tion, due  to  fermentation,  1  grain  (0.065  Gm.)  of  creosote 
may  be  added  to  this  powder.  If  the  bowels  become  too 
loose,  the  magnesia  should  be  withdrawn.  It  is  well  to 
determine  the  necessity  of  the  use  and  the  dosage  of  these 
antacids  by  ascertaining  the  acidity  of  the  gastric  content  at 
some  time  between  or  toward  the  end  of  each  feeding,  since 
it  is  their  purpose  to  neutralize  the  excess  free  hydrochloric 
acid,  and  thereby  facilitate  healing. 

During  this  third  week  anemia  may  be  combated  by  the 
intramuscular  injection  of  sodium  cacodylate  and  the  citrate 
of  iron,  beginning  with  1  grain  (0.06  Gm.)  of  each  every 
second  day,  and  gradually  increasing  the  dose  to  3  grains 
(0.2  Gm.). 

Treatment  from  the  Twenty-second  to  the  Twenty-eighth 
Day.  The  patient  may  now  be  allowed  to  sit  in  a  comfortable 
chair  for  several  hours  each  day,  and  may  be  wheeled  to  sun- 
parlor  or  grounds,  but  should  be  made  to  lie  down  for  one 
hour  after  each  feeding.  The  external  applications  of  heat 
may  now  be  reduced  to  such  times  as  the  patient  is  in  bed. 
The  menu  may  be  increased  by  the  addition  of  such  articles 
as  creamed  sweetbreads,  creamed  chicken,  turkey,  gaiinea-hen, 
squab,  broiled  white  fish,  and  tender  chopped  veal.  Soft  peas, 
tender  string-beans,  bread  and  butter,  dry  toast,  chocolate  and 
cocoa  are  useful.  Otherwise  the  plan  of  the  third  week  is  to 
be  continued.     Should  the  appetite  be'  diminished,  strychnin 


710  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

or  nux  vomica  may  be  prescribed  in  some  simple  stomachic 
vehicle,  such  as  the  compound  tincture  of  gentian  or  the  com- 
pound syrup  of  hypophosphites. 

The  Follow-up  Treatment.  In  no  disease  should  the  fol- 
low-up treatment  call  for  closer  understanding  and  co-opera- 
tion between  the  patient  and  the  doctor,  and  no  complete 
medical  cure  can  be  expected  unless  this  is  so.  Many  ulcers, 
zi'hich  are  zi'ell  on  the  -d.'ay  toward  permanent  healing,  later  relapse 
and  require  surgical  interference  for  idtimate  cure,  as  a  rule,  only 
because  sufficient  emphasis  had  not  been  laid  on  the  after-treat- 
ment. Every  doctor  is  totally  remiss  in  the  responsibility  he 
owes  his  patient  if  he  does  not  make  this  part  of  his  method 
of  treatment  thorough  and  long  sustained,  and  the  patient  is 
glaringly  guilty  of  thoughtlessness  and  indifference  to  the  best 
interest  of  his  health,  if  he  does  not  realize  the  wisdom  of  the 
instructions  given  him. 

During  the  fifth  and  sixth  weeks  of  the  cure  the  plan  of 
the  fourth  week  is  to  be  maintained,  and  especially  is  this  true 
regarding  the  continuance  of  bodil}^  and  mental  rest.  As 
much  of  the  time  as  possible  should  be  spent  lying  down,  or 
pursuing  any  gentle  occupation  that  does  not  entail  physical 
exertion.  Usually  after  the  sixth  week  partial  resumption  of 
business  duties  or  household  aff'airs  may  be  begun,  and  mod- 
erate exercise  may  be  resumed,  at  first  in  the  form  of  walking 
only.  Later  golf  is  permissible,  at  first  a  few  holes,  and  never 
more  than  eighteen,  may  be  played  on  any  one  day.  Games 
requiring  more  violent  exercise,  such  as  handball,  boxing, 
tennis,  rowing,  swimming,  horseback  riding,  polo,  and  the  like, 
must  be  postponed  for  at  least  six  months.  Plentj^  of  hours 
should  be  devoted  to  sleep,  and  at  least  ten  to  twelve  hours  of 
the  twenty-four  should  be  passed  in  the  recumbent  position. 

Patients  should  be  urged  to  lie  down  for  at  least  one-half 
hour  after  each  meal.  During  the  period  of  physical  inactiv- 
ity the  muscles  and  skin  may  be  kept  in  a  state  of  good  tone 
by  the  use  of  electricity  or  hydrotherapy.  In  certain  cases, 
especially  those  constipated,  this  will  prove  of  exceptional 
advantage,  and  for  sluggish  bowels  the  Bergonie  method  of 
electrical  treatment  is  to  be  recommended.  The  bowels  should 
be  kept  well  opened  during  the  period  of  physical  inactivity, 
to  insure  which  they  need  to  be  aided  by  the  occasional  use 


ULCER  Ol'"  Tlll<:  STOMACH   AXMJ  DCODENUM.     '       711 

of  simple  enemas,  or  the  use  of  liquid  paraffin,  Carlsbad  or 
other  mildly  laxative  alkaline  waters ;  or  the  use  of  mag- 
nesium oxide  in  powder  form,  combined  with  soda  bicarbo- 
nate, in  a  dosage  of  5  to  10  grains  (0.324  to  0.65  Gm.)  each, 
to  be  given  after  or  between  meals,  at  the  high-point  of  gas- 
tric secretion,  as  determined  by  fractional  analysis;  if -pre- 
ferred, the  milk  of  magnesia,  in  teaspoonful  (3.75  mils)  doses, 
may  be  substituted  for  this  purpose.  If  it  is  found  that  the 
gastric  secretions  continue  too  highly  acid  or  in  increased 
amounts,  it  is  advisable  to  return  to  the  use  of  silver  nitrate 
as  detailed  above,  or  atropin  or  its  derivatives  may  be  admin- 
istered, subcutaneously  or  by  mouth,  to  a  point  of  physiologic 
effect.  If  the  gastric  analyses  show  hyperacidity,  antacids 
such  as  recommended  above  should  be  used.  If  hypersecretion 
continues  the  stomach  should  be  emptied  night  and  morning, 
by  means  of  a  gastric  or  duodenal  catheter  and  a  small  aspi- 
rating syringe.  Most  patients  become  readily  accustomed  to 
this  form  of  tube,  and  many  of  them  prove  capable  of  doing 
this  for  themselves.  As  to  general  hygiene,  especially  as 
regards  the  care  of  the  mouth,  teeth  and  skin,  patients  who 
have  undergone  active  treatment  will  prefer  to  continue  the 
use  of  such  toilets  indefinitely,  but,  nevertheless,  it  should  be 
made  a  part  of  their  instructions. 

The  use  of  alcohol  in  all  forms,  and  especially  the  highly 
concentrated  ones,  such  as  cocktails,  should  be  prohibited  for 
at  least  six  months,  with  the  exception  of  a  glass  or  two  of 
a  good  claret,  or  Rhine  wine,  or  the  use  of  rye  or  Scotch 
whisky,  occasionally,  in  the  form  of  a  highball  with  plain 
water,  for  those  who  are  accustomed  to  its  use.  This  will 
probably  do  them  no  harm,  but  it  is  wiser  to  urge  total 
abstinence.  All  effervescent  or  aerated  drinks  should  be  pro- 
hibited. Free  use  of  a  mild  alkaline  water,  such  as  Celestins 
Vichy,  should  be  encouraged.  Smoking  should  be  abstained 
from  for  at  least  six  months,  with  the  exception  of  the  occa- 
sional use  of  a  mild  cigar  after  meals.  Tobacco  in  any  other 
form,  especially  chewing,  should  be  prohibited. 

Finally,  no  part  of  the  after-treatment  is  more  important 
than  the  adherence  to  a  proper  diet,  for  at  least  six  months 
to  a  year,  after  the  period  of  active  treatment.  In  general,  all 
food  that  stimulates  gastric  secretion  or  causes  hyperperis- 


712  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

talsis,  should  be  entirely  interdicted.  This  will  include  all 
the  spices  and  condiments,  such  as  paprika,  pepper,  mustard 
and  horse-radish;  salt  should  be  used  sparingly;  likewise 
sauces,  such  as  tomato  catsup,  chili,  Worcestershire  and  Oscar 
sauces,  or  the  use  of  such  vegetables  as  onions,  radishes, 
leeks,  cucumbers  and  tomatoes;  or  pickles,  mixed  pickles,  and 
acid  fruits  of  the  citrate  family,  cherries,  bananas,  and  the 
like.  All  such  articles  of  food  should  be  forbidden.  Fresh 
fruits  should  be  indulged  in  only  sparingly,  and  it  is  better 
to  give  preference  to  the  cooked  forms.  Likewise,  all  fried 
foods,  hot  breads  and  pastries,  all  rich  dressings,  gravies  and 
sauces,  or  rich  desserts,  and  all  meats  tough  with  connective 
tissue,  and  scratchy  vegetables  with  outer  shells  of  cellulose, 
such  as  corn  and  celery,  should  be  abstained  from  for  at  least 
a  year,  if  possible.  Emphasis  should  be  laid  upon  the  neces- 
sity of  thorough  mastication.  Great  care,  too,  should  be  taken 
not  to  overload  the  stomach  at  any  one  time.  This  applies  to 
both  liquids  and  solids,  and  it  is  wiser  to  adopt  a  five-  or  six- 
meal  plan  of  feeding  in  small  amounts.  Very  hot  or  very  cold 
foods  should  not  be  taken.  The  patient  should  make  it  a  prac- 
tice to  lie  down  for  at  least  one-half  hour  after  each  meal. 

As  to  what  may  be  eaten,  the  writer  recommends  the  use 
of  the  following  menu,  which  has  served  him  well  in  the  past : 

Breakfast.  A  cooked  cereal,  such  as  farina,  wheatena, 
cream  of  wheat  or  hominy  may  be  eaten  with  cream  and 
sugar.  Oatmeal  may  be  allowed,  if  very  thoroughl}'  cooked. 
An  occasional  lamb-chop  or  slice  of  breakfast  bacon.  Two 
soft-boiled  or  poached  eggs.  The  soft  parts  of  bread,  crackers 
or  freshly  made  toast  may  be  eaten  with  butter.  Milk,  malted 
milk  or  cocoa  may  be  taken.  It  is  better  to  avoid  both  tea 
and  coffee,  although  they  may  be  used  for  flavoring. 

10  to  11  A.M.  The  choice  of  the  cream  and  rice-water  for- 
mula, malted  milk,  koumiss,  keffir  or  buttermilk,  or  equal  parts 
of  milk  and  cream,  junket  or  cup-custard.  One  or  two  raw 
eggs  may  be  substituted  or  added  to  any  of  the  foregoing. 
Crackers  and  butter. 

Luncheon  or  Dinner.  Chicken  or  fish  in  any  form  but  fried, 
broiled  squab,  or  the  breast  of  guinea-hen.  Broiled  or  boiled 
beef  and  lamb,  to  be  run  through  a  grinder  when  cooked. 
Milk-toast.     Oysters  in  any  form  but  fried.     Potatoes  in  any 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  7l3 

form  but  fried,  preferably  mashed  or  baked.  Peas,  lima  beans, 
spinach,  squash  (to  be  put  through  a  colander  and  pureed 
with  cream),  boiled  rice,  tender  string-beans,  buttered  beets, 
creamed  carrots,  or  the  tender  ends  of  asparagus  and  cauli- 
flower, spaghetti  or  macaroni.  A  salad  of  plain  lettuce  with 
French  dressing  (with  the  amount  of  vinegar  reduced)  may 
be  permissible  every  second  or  third  day  if  desired.  Bread 
and  butter.  Choice  of  junket,  cup-custard,  blanc  mange, 
tapioca,  rice,  cornstarch  or  bread-puddings,  floating  island  and 
vanilla  ice-cream  (if  held  in  the  mouth  and  warmed  to  body 
temperature). 

4  to  5  P.M.    The  same  choice  as  at  10  a.m. 

Supper  or  Dinner.  Thick  soups,  such  as  rice,  sago,  barley, 
farina,  potato  or  asparagus,  or  creamed  purees  of  beans,  peas 
or  lentil,  which  are  to  be  run  through  a  colander.  No  soups 
made  from  meat  or  meat-stock  are  allowed.  One  or  two  soft- 
boiled  or  poached  eggs.  Bread  and  butter.  Milk  or  cocoa, 
and  the  choice  of  any  of  the  above  desserts,  except  ice-cream. 

Before  retiring,  the  choice  of  the  foods  allowed  at  4  p.m. 

During  the  course  of  this  after-treatment  the  patient 
should  be  in  personal  or  written  communication  with  his 
physician,  perferably  the  former,  every  two  weeks  for  a  period 
of  at  least  six  months,  preferably,  a  year,  so  that  the  earliest 
signs  and  symptoms  of  an  exacerbation  can  be  detected 
promptly.  During  this  period  a  physical  examination,  to 
include  particularly  an  inspection  of  the  mouth  and  teeth,  an 
abdominal  examination,  and  routine  analyses  of  gastric  secre- 
tion and  chemical  analyses  of  the  stools,  should  be  made  at 
least  once  a  month.  It  is  the  writer's  firm  belief  that  if  this 
plan  of  medical  management  of  ulcer  cases  is  adopted  in  its 
entirety,  a  larger  number  of  real  medical  cures  will  be  secured, 
with  a  consequent  lessening  of  the  number  of  patients  who 
otherwise  would  require  operative  interference.  Unless  there 
are  already  existing  complications  or  sequelae  of  gastric  or 
duodenal  ulcer,  as  outlined  above,  every  case  should  be  given 
the  benefit  of  medical  treatment  before  resorting  to  surgery. 
This  applies  particularly  to  the  border-line  group.  No  med- 
ical plan  of  management,  however,  can  be  relied  upon  to 
secure  results,  unless  it  is  thoroughly  planned  and  rigidly 
.  adhered  to,  and  every  physician  should  devote  as  much  pains- 


714  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

taking"  care  in  the  working-  out  of  the  detail  of  his  technic  as 
that  which  pervades  the  operating  room  of  every  thoroughly 
capable  surgeon.  If  the  medical  regime  cannot,  for  one  rea- 
son or  another,  be  thoroughly  carried  out,  the  preference 
should  be  given  to  the  aseptic  scalpel,  but  only  when  wielded 
by  the  hand  of  the  experienced  full-time  surgeon.  If  there  is 
one  thing  worse  than  poor  medicine  or  medical  management, 
it  is  poor  surgery. 

There  is  a  certain  number  of  ulcer  cases  that,  even  with 
the  best  of  medical  handling,  will  relapse  in  the  sense  of  giv- 
ing signs  and  symptoms  of  ulcer  activity.  In  these  cases  no 
further  expectation  of  medical  cure  can  be  hoped  for,  and  the 
case  then  becomes  amenable  only  to  surgical  interference.  If 
the  case  is  uncomplicated  to  begin  with,  one  wall  rarely 
see  the  development  of  complications  under  this  medical 
plan. 

Method  of  Duodenal  Feeding  in  Gastric  and  Duodenal 
Ulcer.  In  recent  years  there  has  been  a  larger  number  of 
cases  of  ulcer  treated  by  a  plan  first  suggested  by  Einhorn, 
nearly  a  decade  ago,  and  since  modified  by  many.  This  plan 
aims  at  short-circuiting  the  stomach  and  doudenum  and  the 
establishment  of  physiologic  rest,  in  the  sense  that  no  food 
is  to  be  allowed  to  pass  across  the  ulcerated  area.  This  is 
supposed  to  be  accomplished  by  the  use  of  a  duodenal  tube 
or  catheter,  of  a  type  first  devised  by  Einhorn,  and  later  modi- 
fied by  Rhefuss  and  others,  which  is  passed,  or  swallowed  by 
the  patient,  until  it  reaches  a  point  in  the  second  portion  of 
the  duodenum  below  the  point  of  ulceration.  This  point  may 
be  determined,  in  many  cases,  by  the  string  test  if  the  ulcer 
is  a  bleeding  one,  or  by  fluoroscopic  or  rontgen  plate  analysis 
when  interpreted  by  an  expert.  After  this  point  has  been 
determined  and  the  duodenal  catheter  has  been  passed,  it  is 
an  essential  that  a  second  fluoroscopic  examination  should  be 
made  to  determine  that  the  metal  tip  lies  in  the  duodenum 
beyond  the  point  of  ulceration.  For  this  form  of  treatment  to 
result  successfully,  it  is  almost  a  necessity  that  the  patient 
should  be  in  a  properly  equipped  hospital,  since  it  is  often 
wise  to  refluoroscope  the  patient  every  few  days,  to  make  sure 
that  the  end  of  the  tube  has  not  been  regurgitated  back  into 
the  stomach.     This  occurrence,  which  is  not  uncommon  in 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  715 

the  writer's  rather  Hmited  experience  with  this  method,  will 
entirely  negative  any  possihility  of  success. 

The  duodenal  tube  should  be  at  least  1  meter  (39.37  in.) 
long  and  made  of  good  rubber  with  a  caliber  of  about  3 
millimeters  (0.12  in.),  and  should  be  marked  at  distances  of 
55,  70  and  80  centimeters  (21.649,  27.559  and  31.496  in.)  from 
the  capsule  end.  The  first  mark  represents  the  distance  from 
the  incisor  teeth  to  the  greater  curvature  of  the  stomach  in 
the  average  case.  The  additional  distance  of  15  centimeters 
(5.866  in.)  will  usually  carry  the  tube  well  into  the  duodenum, 
and  it  should  never  be  allowed  to  pass  further  than  the  third 
mark.  If  there  is  an  associated  gastroptosis  an  allowance  of 
distance  should  be  made  according  to  the  position  of  the 
stomach. 

The  metal  tip  should  be  of  a  kind  that  will  not  corrode  by 
contact  with  the  gastric  juice,  and  provided  with  slots  or  per- 
forations which  are  equal  in  caliber  to  the  lumen  of  the  tube. 
It  should  be  made  the  rule  ahuays  to  provide  fresh  rubber 
tubing  for  each  patient  so  treated,  and  to  see  that  the  metal 
tip  is  properly  and  securely  tied  into  the  tube  with  a  fine 
surgeon's  silk. 

The  tube  may  be  either  introduced  through  the  mouth  or 
through  one  of  the  nostrils,  and  should,  preferably,  be  passed 
at  night.  If  fluoroscopic  facilities  are  not  at  hand  to  confirm 
the  proper  position  of  the  metal  capsule,  the  following  points 
may  be  carried  out :  First,  the  tube  should  have  reached  the 
second  marking,  or  a  point  between  the  second  and  third 
marking;  second,  when  gentle  traction  is  exerted  a  sense  of 
resistance  and  tautening  of  the  tube  will  be  felt;  third,  by 
gentle  aspiration  there  should  be  recovered  a  material  that,  in 
color  and  chemical  examination,  should  conform  to  that  of 
the  duodenal  juice;  and,  fourth,  water,  or  preferably  milk, 
when  swallowed  cannot  promptly  be  aspirated  through  the 
tube.  When  the  tube  has  reached  the  desired  point  it  should 
be  securely  held  in  place  by  strapping  with  adhesive  plaster, 
carried  across  the  cheek,  with  the  proximal  end  of  the  tube 
adjusted  back  of  the  ear,  and  fastened  to  the  ear  by  a  rub- 
ber band;  when  not  in  use  the  tube  should  be  properly 
clamped  ofif. 

The  foods  given  must  necessarily  be  liquids,  and  Einhorn 


716  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

recommends  the  use  of  milk,  lactose,  and  raw  eggs  in  the  pro- 
portion of  1  glass  of  milk,  1  €:gg,  and  1  tablespoonful  (15 
mils)  of  lactose.  This  should  be  stirred  thoroughh-  and 
heated  very  slowly  to  avoid  lumpiness,  due  to  coagulation  of 
egg- albumin,  and  should  be  injected  very  slowly  every  two 
hours  from  7  a.m.  to  9  p.m.,  at  a  temperature  of  from  100°  to 
105°  F.  (37.5°  to  40.5°  C).  The  amount  of  each  feeding 
should  at  first  be  100  mils  (3.34  ozs.),  gradually  increasing 
to  250  mils  (8.34  ozs.).  Amounts  larger  than  this  are  likely 
to  cause  increased  duodenal  distention,  even  if  given  slowly. 

Later,  feedings  may  be  given  at  intervals  of  one  and  a 
half  hours,  so  that  the  total  caloric  value  approximates  2500 
to  3000  calories.  Before  each  feeding  about  an  ounce  (30 
mils)  of  sterile  salt  solution,  or  preferably,  decinormal  solu- 
tion of  soda  bicarbonate  should  be  introduced  through  the 
tube,  and  following  each  feeding  a  similar  procedure  should 
be  carried  out,  and  this  followed  by  the  injection  of  a  syringe- 
barrelful  of  air.  This  serves  to  cleanse  the  tube  of  the  feed- 
ing formula,  and  to  keep  it  clean,  which  is  of  the  utmost 
importance.  If  abdominal  distention  or  flatulency  occur,  the 
feeding  formula  should  be  peptonized  with  pancreatic  pow- 
der. The  writer  prefers  the  method  suggested  by  W.  G.  Mor- 
gan, of  placing  the  proper  amount  of  the  feeding  formula  in 
a  graduated  glass  tank  and  feeding  by  a  drop-method,  similar 
to  the  Murphy  method  of  proctoclysis,  with  the  rate  of  flow 
so  adjusted  that  it  will  require  fifteen  minutes  to  introduce 
each  100  mils  (3.34  ozs.)  of  the  mixture. 

In  patients  who  are  considerably  emaciated  Smithies  re- 
commends the  feeding  of  a  mixture  of  amino-acid  and  maltose. 
This  mixture  is  prepared  by  "first  digesting  Witte  peptone 
in  normal  salt  by  trypsin  (Fairchild)  under  toluol,  or  in  0.4 
per  cent,  alphozone-normal  salt  solution,  and  then  adding 
sufficient  maltose  to  make  a  5  per  cent,  mixture."  He  gives 
amounts  of  from  100  to  500  mils  (3.34  to  19.99  ozs.)  of  this 
mixture  through  the  duodenal  catheter  every  three  hours,  and 
if  thirst  is  excessive  he  gives  an  equal  amount  of  normal  salt 
solution  about  ten  minutes  before  the  animo-acid-maltose 
mixture. 

These  duodenal  feedings  may  be  kept  up  for  a  period 
ranging    between    fourteen    and    twenty-one    days;    shorter 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  717 

periods  than  this  cannot  be  expected  to  make  much  head- 
way in  the  healing  of  an  ulcer.  During  this  period  it  may 
be  wise  to  reinforce  the  duodenal  feedings  with  a  nutrient 
enema  each  day,  and  the  use  of  decinormal  soda  bicarbonate 
in  the  dosage  previously  described.  After  the  second  or  third 
week  of  treatment  the  duodenal  feeding  should  differ  in  no 
wise  from  that  which  is  recommended  in  the  foregoing  para- 
graphs. Complete  bed-rest,  hygiene,  external  applications  of 
heat,  and  the  follow-up  plan  of  treatment  should  be  just  as 
energetically  carried  out. 

As  a  rule,  in  patients  who  become  tolerant  to  its  presence 
it  is  not  necessary  to  remove  the  duodenal  tube  until  the 
desired  time  limit  has  expired,  if  great  care  is  practised  in 
keeping  the  tube  cleansed  after  each  feeding.  After  the  tube 
has  been  permanently  withdrawn,  feedings  by  mouth  may  be 
resumed  by  adopting  the  Lenhartz  method,  or  the  plan  re- 
commended above.  If  chemical  therapy  is  indicated,  medicine 
such  as  the  tincture  of  belladonna,  from  5  to  15  minims  (0.30 
to  0.92  mil),  may  be  introduced  through  the  tube,  directly 
into  the  duodenum,  provided  it  is  sufficiently  diluted.  If 
there  is  associated  anemia,  increasing  doses  of  Fowler's  solu- 
tion, from  5  minims  (0.30  mil),  diluted  with  15  mils  (250  m.) 
of  water,  may  be  given  through  the  tube  two  or  three  times 
a  day.  The  writer  has  also  used  5  grains  (0.325  Gm.)  of 
ichthyol,  dissolved  in  15  mils  (0.5  oz.)  of  water,  approxi- 
mately a  2  per  cent,  solution,  given  through  the  tube  two  or 
three  times  a  day  in  a  case  with  associated  ileocolitis,  with 
apparently  beneficial  results.  If  the  pancreatic  ferments  show 
diminished  activity,  substitution  products  may  be  likewise 
administered.  The  antacids  are  not,  as  a  rule,  indicated,  and 
if  they  are,  they  should  be  administered  by  mouth  to  take 
effect  in  the  stomach. 

As  stated  before,  the  writer's  experience  with  duodenal 
feeding  for  gastric  or  duodenal  ulcer  has  been  a  limited  one, 
and  he,  therefore,  does  not  feel  qualified  to  speak  emphatic- 
ally, either  in  praise  or  in  criticism  of  this  method.  Never- 
theless, his  belief  is  that  it  is  in  no  way  superior  to  the 
method  described  above,  and  the  suspicion  may  be  tenable, 
that  it  is  even  productive  of  more  harm  than  good,  for  the 
following  reasons :    The  writer  has  seen  several  cases,  well 


/18  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

tube-broken,  who  have  become  intensely  intolerant  to  the 
presence  of  the  duodenal  tube  when  kept  in  situ  for  periods 
rang-ing  from  twenty-four  hours  to  seven  days.  In  all  these 
patients  the  metal  capsule  was  regurgitated  back  into  the 
stomach,  and  this  was  preceded  by  midepigastric  sensations 
varying  from  simple  discomfort  to  acute  pain.  In  two  of 
these  patients,  occult  blood,  not  present  in  the  gastric  con- 
tents or  in  the  stools  before  treatment  was  begun,  could  be 
demonstrated  after  the  tube  was  withdrawn.  In  one  other 
case,  the  fluoroscopic  study,  which  before  treatment  was  be- 
gun corroborated  the  clinical  diagnosis  of  duodenal  ulcer 
only,  on  re-examination  after  the  tube  had  been  regurgitated, 
gave  evidence  strongl}^  suggestive  of  prepyloric  erosion,  fur- 
ther substantiated  by  the  fact  that  the  patient  had  vomited 
small  amounts  of  dark-brownish  vomitus,  strongly  positive 
for  occult  blood,  which  led  to  the  determination  to  withdraw 
the  tube.  The  writer  is  of  the  opinion  that  in  all  of  these 
cases  the  constant  presence  of  the  tube  was  the  direct  cause 
of  these  symptoms  and  findings,  inasmuch  as  these  patients 
progressed  satisfactorily  when  placed  upon  the  writer's  usual 
plan  of  treatment.  Again,  it  has  been  noted,  frequently,  that 
in  fluoroscoping  patients  with  the  duodenal  tube  iji  situ  there 
is  a  considerably  increased  peristalsis,  with  associated  pyloro- 
spasm.  Such  an  observation  is  not  in  accord  with  the  writer's 
idea  of  gastric  physiologic  rest,  and  he  believes  that  the  pas- 
sage of  a  bland  liquid  food  over  an  ulcerated  area  will  not 
cause  as  much  irritation  as  the  constant  presence  of  a  foreign 
body.  Duodenal  feeding  may  have  a  place  in  the  treatment 
of  ulcer,  but  the  writer  confesses  to  a  doubt  on  this  point. 

TREATMENT    OF    SPECIAL    SYMPTOMS    AND 
COMPLICATIONS. 

Pain.  Pain  is  usually  entirely  controlled  by  complete  rest 
in  bed,  by  the  use  of  external  applications  of  heat  or  cold, 
and  by  the  use  of  alkalies,  silver  nitrate,  or  belladonna;  or, 
when  due  to  hypersecretion,  by  aspiration  of  the  stomach  con- 
tents two  to  four  times  a  day,  using  the  duodenal  catheter  for 
this  purpose,  as  described  below.  Where  these  measures  do 
not  suffice  and  epigastric  pain  continues  to  be  a  prominent 
symptom,  it  argues  in  favor  of  a  mistake  in  diagnosis. 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  719 

Hypersecretion,  It  is  doubtful  whether  hypersecretion 
ever  occurs  in  a  simple  ulcer,  but  it  is  one  of  the  most  fre- 
quent complications  of  ulcer,  and  is  almost  invariably  due  to 
pyloric  obstruction,  as  a  result  of  cicatricial  contraction, 
adhesions,  inflammatory  edema,  or  pylorospasm.  The  last  two 
lesions  are  amenable  to  medical  management,  while  cicatricial 
stenosis  will  require  surgical  interference.  The  most  effect- 
ive relief  is  obtained  by  periodically  emptying  the  stomach  of  its 
irritating  content.  This  can  be  accomplished  best  by  aspirat- 
ing the  stomach  contents,  and  for  this  purpose  the  writer 
prefers  to  use  a  metal-tipped  duodenal  catheter,  and  to  start 
emptying  the  stomach  with  a  simple  1-  or  2-  ounce  (30  or  60 
mils)  catheter-tipped  syringe,  after  which  the  contents  may 
continue  to  flow  steadily  from  the  stomach.  If  not,  succes- 
sive syringefuls  may  be  withdrawn  until  the  viscus  is  empty. 
It  is  good  practice  then  gently  to  lavage  the  stomach  by 
injection  through  the  tube  of  a  weak  solution  of  silver  nitrate, 
not  more  than  200  mils  (6.67  ozs.)  in  a  strength  of  from 
1:6000  to  1:4000.  This  should  be  then  aspirated  and  fol- 
lowed by  2  or  3  syringefuls  of  sterile  water,  and  this  by  200 
mils  (6.67  ozs.)  of  any  bland  alkaline  solution.  When  the 
stomach  is  lavaged  with  such  small  amounts  the  tube  should 
be  withdrawn  3  or  4  inches  (7.62  or  10.16  cm.),  or  until  the 
metal  tip  lies  just  below  the  cardiac  orifice  of  the  stomach,  so 
that  the  stomach-walls  are  gently  sprayed  from  top  to  bottom 
with  the  lavaging  fluid;  to  aspirate,  the  tube  must  be  intro- 
duced further,  so  that  the  capsule  lies  along  the  greater  curva- 
ture. This  method  is  greatly  superior  to  lavage  by  means  of 
the  usual  stomach-tube,  and  is  very  well  tolerated  by  most 
patients,  especially  when  they  have  appreciated  the  amount 
of  relief  that  can  be  obtained  thereby.  The  frequency  with 
which  this  should  be  done  must  depend  upon  the  amount  of 
the  secretion  and  its  acid  concentration,  but,  as  a  rule,  the 
empty  morning  stomach  should  be  so  treated,  to  prepare  the 
patient  for  the  day,  and  again  at  night  to  assure  the  patient 
a  good  night's  rest.  Three  or  four  times  in  the  twenty-four 
hours  usually  will  be  sufficient  for  the  more  pronounced 
cases. 

In  the  writer's  opinion  this  is  a  much  more  rational 
and  effective  procedure  in  combating  the  symptom  than  by 


720  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

attempting  to  neutralize  the  acid  secretion  with  alkaline 
medicaments. 

In  patients  who  are  intolerant  to  the  tube  the  throat  may 
be  sprayed  with  a  1  or  2  per  cent,  solution  of  cocaine,  and 
after  lavaging  a  3  per  cent,  solution  of  anesthesin  in  1  ounce 
of  olive  oil  may  be  introduced  through  the  tube. 

Vomiting.  Milder  grades  of  vomiting  can  usually  be 
relieved  by  the  use  of  cerium  oxalate,  bismuth  subcarbonate, 
and  some  form  of  magnesia.  A  combination  powder,  in  small 
doses,  msLj  be  made  up  to  contain  cerium  oxalate,  3  grains 
(0.2  Gm.)  ;  bismuth  subcarbonate,  10  grains  (0.6  Gm.)  ;  mag- 
nesia usta,  5  grains  (0.3  Gm.).  Such  a  powder  may  be  given 
four  or  five  times  at  hourly  interv^als,  and  if  relief  is  not 
obtained  the  vomiting  is  probably  due  to  reflex  causes.  Of 
these,  pylorospasm  may  be  controlled  by  hypodermics  of 
atropin  in  a  dosage  of  %oo  grain  (0.0006  Gm.),  to  be  repeated 
every  second  hour  lintil  physiologic  effect  is  secured.  One 
grain  (0.06  Gm.)  of  powdered  belladonna  may  be  added  to 
the  foregoing  combination,  or  belladonna  may  be  adminis- 
tered in  the  form  of  the  tincture,  giving  10  minims  (0.6  mil) 
every  two  or  three  hours,  or  until  physiologic  effects  are 
secured.  The  use  of  these  antispasmodics  is  likewise  indi- 
cated where  the  vomiting  is  due  to  pylorospasm  complicated 
by  hypersecretion,  but  if  relief  from  vomiting  is  not  promptly 
afforded  the  writer  has  found  nothing  so  effectual  as  constant 
drainage  of  the  stomach  for  one  or  two  hours  by  means  of 
the  duodenal  catheter.  This  should  be  passed  into  the  stom- 
ach, strapped  to  the  cheek  at  the  desired  point,  and  with  a 
small  glass  connecting  tube  a  second  piece  of  rubber  tubing 
is  attached,  long  enough  to  be  carried  down  to  an  out-flow 
pail.  The  stomach  contents  should  be  aspirated  by  syringe 
and  the  stomach  lavaged  gently  with  syringefuls  of  sterile 
water,  followed  by  mild  alkaline  solutions,  such  as  soda  bicar- 
bonate 31  to  1000  mils  (1.03  to  33.33  ozs.)  of  water,  or  a  bland 
alkaline  solution.  The  return  of  these  lavaging  fluids  should 
be  started  by  syringe  or  bulb  aspiration,  after  which  the 
stomach  usually  drains  itself  by  gravity.  Lavage  should  be 
repeated  every  fifteen  minutes  for  one  hour,  using  not  more 
than  500  mils  (19.99  ozs.)  as  the  total  for' each  lavage,  and 
alternating  the  use  of  the  alkaline  solution  with  one  contain- 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  721 

ing  1  ounce  (30  mils)  of  the  tincture  of  belladonna  in  500  mils 
(19.99  ozs.)  of  water.  One  or  two  hours  of  this  treatment  will 
usually  be  effective,  but  it  may  be  continued  for  longer 
periods,  if  necessary.  This  is  far  easier  for  the  patient  than 
the  exhaustion  which  follows  repeated  vomiting,  especially  if 
accompanied  by  much  retching.  Great  care  should  be  taken 
to  see  that  the  persistent  vomiting  is  not  due  to  an  acutely 
dilated  stomach  due  to  a  high  duodenal  obstruction,  to  angu- 
lation, or  to  a  mesenteric  ileus,  as  is  occasionally  seen  in  ulcer 
with  complicating  pyloric  obstruction  consequent  to  gastro- 
ptosis.  In  such  cases  the  foot  of  the  bed  should  be  well 
elevated,  and  the  patient  turned  to  the  right  or  left  lateral 
abdominal  position,  lying  over  a  sand-bag  or  a  bolster  pillow, 
which  is  to  be  placed  just  below  the  level  of  the  navel;  the 
use  of  constant  stomach  drainage,  as  described  above,  should 
be  continued,  and,  in  addition  to  this,  the  writer  in  several 
cases  has  seen  excellent  results  follow  the  use  of  the  spon- 
dylo-therapeutic  maneuver,  described  in  detail  on  page  824, 
in  the  section  on  the  treatment  of  acute  dilatation  of  the 
stomach.  In  these  extreme  types  of  vomiting  all  food  is  to 
be  withheld  by  mouth  until  the  stomach  becomes  tolerant, 
when  feeding  is  to  be  resumed  most  carefully,  and  with  small 
amounts  of  liquids. 

In  cases  where  the  vomiting  is  reflexly  due  to  intestinal 
hyperperistalsis,  it  may  often  be  relieved  by  the  use  of  opium 
suppositories. 

Hemorrhage.  Adrenalin  is  the  most  efificient  drug  for  the 
relief  of  this  complication.  It  should  be  given  in  a  dosage  of 
10  minims  (0.6  mil)  of  the  1 :  1000  solution,  and  repeated 
every  fifteen  minutes  for  several  doses.  By  its  action  the 
blood-vessel  is  contracted  long  enough  for  thrombosis  to 
occur.  Should  this  not  prove  effectual,  lavage  with  ice-water 
has  proved  a  safe  procedure,  being  first  recommended  by 
Ewald,  and  since  endorsed  by  many  others.  Before  this  is 
attempted  it  is  wise  to  give  a  hypodermic  of  morphine  to  alia}- 
restlessness  and  to  quiet  the  nervous  apprehension  of  the 
patient,  and  the  throat  should  be  sprayed  with  a  1  or  2  per 
cent,  solution  of  cocaine.  It  is  important  to  perform  lavage 
rapidly,  and  this  can  best  be  facilitated  by  the  use  of  the 
Leube-Rosenthal  method,  with  an  irrigation  tank  connected 

4G 


722  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

with  the  stomach-tube  and  attached  to  one  limb  of  a  glass 
connection,  with  an  outflow  tube  attached  to  the  other.  This 
is  a  much  quicker  method,  and  easier  for  the  patient.  If 
restlessness  continues  no  drug  is  of  such  serv-ice  as  morphin, 
which  should  be  administered  to  the  point  of  mild  narcotiza- 
tion. If  the  hemorrhage  be  massive  and"  the  patient  becomes 
exsanguinated,  proctoclysis  and  h3-podermoclysis  should  be 
practised.  Direct  transfusion  may  have  to  be  resorted  to  in 
some  cases,  and  the  writer  can  thoroughly  recommend  the 
use  of  the  Kimpton-Brown  tubes  for  this  purpose.  Aside 
from  the  trick  of  properly  coating  the  tubes  with  paraffin  the 
technic  of  their  method  is  extremely  simple.  It  is  wise  to 
dela}'  the  building  up  of  the  body  fluids  by  proctoclysis  for 
perhaps  an  hour,  to  minimize  the  risk  of  dislodging  a  form- 
ing thrombus. 

While  profuse  gastric  hemorrhages  are  exceedingly  terri- 
fying to  the  patient  and  members  of  the  famity,  and  alarming 
even  to  the  doctor,  it  is  well  to  remember  that  few  of  such 
hemorrhages  result  in  immediate  fatality,  and  the  greater 
majority  of  such  patients  may  be  saved. 

An  ice-bag  should  be  immediately  and  constant!}^  applied 
to  the  epigastrium.  All  food  given  b}'  mouth  should  be 
stopped,  and  not  begun  again  until  all  evidence  of  fresh 
melena  has  ceased,  perhaps  even  until  occult  blood  can  no 
longer  be  found  in  the  stools.  These  two  measures  prevent 
unnecessary  movement  of  the  stomach,  and  keep  down  gas- 
tric secretion,  which  might  dislodge  a  thrombus  or  digest  a 
clot.  Nourishment  is  to  be  begun  by  rectal  enemata.  (C/.  p. 
699).  The  patient  is  to  be  kept  flat  on  the  back,  and  not  a 
single  unnecessary  movement  allowed.  When  oral  feeding  is 
resumed  it  should  follow  the  general  plan  outlined  on  page  703. 

In  a  few  cases  surgical  interference  must  be  resorted  to, 
and  this  is  particularly  indicated  in  the  constant  oozing  from 
an  eroded  blood-vessel,  which  resists  all  medical  measures, 
and  in  which  the  life .  of  the  patient  is  threatened,  if  the 
bleeding  continues.  The  operative  decision  should  be  made 
promptly  when  it  is  seen  that  the  hemoglobin  estimations  are 
constantly  decreasing,  and  should  not  be  delayed  until  the 
hemoglobin  falls  to  a  point  that  materially  increases  the 
operative  risk.     The  stomach  should  be  opened,  the  bleeding 


ULCER  OF  THE  STOMACH  AND  DUODENUM.  723 

vessel  caught  and  ligated,  the  eroded  surface  cauterized,  and 
a  gastroenterostomy  performed;  in  certain  cases  the  ulcer 
may  be  excised.  This  sounds  easy,  but  in  reality  it  is  no 
mean  surgical  feat,  even  in  the  hands  of  the  most  expert.  The 
patient  should  be  given  transfusion  with  normal  salt  solution, 
together  with  proctoclysis  and  hypodermoclysis  just  before 
and  again  after  operation. 

Perforation.  This  complication  is  an  imperative  indica- 
tion for  an  immediate  laparotomy.  The  diagnosis  should  be 
easily  made,  and  precious  hours  should  not  be  wasted  before 
moving  the  patient  to  the  operating  room  and  the  septic 
scalpel.  In  probably  no  field  of  surgery  does  the  life  of  the 
patient  depend  so  much  upon  prompt  and  concerted  action 
on  the  part  of  the  physician  and  the  surgeon,  as  the  mortality 
materially  improves  in  inverse  proportion  to  the  number  of 
hours  that  have  elapsed  since  perforation.  In  good  surgical 
clinics  most  cases  will  recover  if  operated  within  ten  hours 
after  perforation.  The  prognosis  is  good  even  up  to  twenty 
hours,  but  after  twenty-four  hours  the  mortality  rate  rapidly 
increases.  (C/.  p.  688.)  It  is  still  a  mooted  surgical  question 
as  to  whether  the  perforation  alone  should  be  closed  or 
whether  a  gastroenterostomy  should  be  added.  This  is  a 
matter  for  the  surgeons  themselves  to  decide,  and  doubtless 
hinges  upon  the  surgical  skill  and  manual  dexterity  of  the 
individual  operator. 

Secondary  Carcinomatous  Degeneration.  For  this,  prompt 
surgical  interference  is  the  one  and  only  method  of  treatment. 
The  burden  of  diagnostic  proof  should  be  laid  upon  every 
physician  thoroughly  to  rule  out  the  possibility  of  this  seri- 
ous complication.  Every  ulcer  occurring  on  the  gastric  side 
of  the  pylorus  should  be  under  suspicion,  and  the  case  should 
be  critically  studied,  both  historically  and  by  all  laboratory 
maneuvers. 

In  any  case  undergoing  a  medical  plan  of  treatment,  in 
which  there  is  a  gradual  diminution  of  hemoglobin,  a  persist- 
ent but  insignificant  loss  of  weight,  the  persistence  of  blood 
in  the  stools,  and  pain  after  one  week  of  bed-rest  and  the  use 
of  heat  or  cold  to  the  abdomen,  an  exploratory  laparotomy 
should  be  strongly  urged. 


724  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

CARCINOMA    OF   THE    STOMACH. 

Gastric  cancer  is  a  disease  of  the  stomach  in  which  a 
malignant  neoplasm  is  implanted  in  the  mucous  wall  or  lining 
of  the  organ.  It  is  usually  insidious  in  its  onset,  and  progres- 
sively fatal  if  unchecked.  It  is  a  disease  of  all  ages,  but 
occurs  far  most  frequently  during  the  fifth  and  sixth  decades. 
It  is  always  accompanied  by  disturbance  of  gastric  function, 
and,  while  the  symptoms  may  vary  within  wide  limits,  usually 
there  is  a  progressive  diminution  of  motor  and  secretory  func- 
tions and  deficient  digestive  activity,  together  with  the  devel- 
opment of  abnormal  chemical  and  bacterial  findings.  In 
advanced  cases  there  are  always  associated  constitutional 
symptoms  of  anemia,  cachexia,  and  toxemia,  with  depres- 
sions of  the  nervous  system.  We  are  greatly  indebted  to 
Smithies^s  for  the  most  recent  exhaustive  and  statistical 
review  of  the  subject  of  gastric  cancer,  and  the  writer  cor- 
dially acknowledges  the  helpfulness  of  this  source  of  informa- 
tion in  compiling  certain  parts  of  this  section. 

Cancer,  in  general,  is  one  of  the  problems  of  the  day.  If 
statistics  can  be  relied  upon  the  disease  is  on  the  increase, 
actually  as  well  as  relatively.  Hoffman  estimates  that  it  is 
now  25  per  cent,  more  common  than  ten  years  ago,  and  that 
this  increase  is  true  of  the  whole  population  of  the  world. 
Nor  is  this  due  alone  to  our  diagnostic  ability  in  its  better 
recognition.  In  1913  there  were  75,000  deaths  in  the  United 
States  from  cancer,  of  which  gastric  cancer  furnished  the 
highest  mortality  of  all,  and  totaled  38  per  cent,  of  all  cancer 
deaths. 

It  is  a  hopeful  sign,  and  somewhat  indicative  of  the  fact 
that  the  general  practitioner  is  becoming  more  alert  to  the 
possibility  of  gastric  cancer,  that  this  disease  is  too  frequiently 
diagnosed  without  sufficient  data.  In  support  of  this,  Fen- 
wick,''-9  of  London,  states  that  of  56  cases  admitted  to  his 
hospital  service  with  a  diagnosis  of  gastric  cancer,  25  (44.7 
per  cent.)  did  not  have  it,  yet  this  mistake  occurred  in  illnesses 
averaging  twelve  months'  observation,  and  Cabot-*^  reports 
that  of  a  large  number  of  patients  referred  to  him  as  gastric 
cancer  there  was  28  per  cent,  of  diagnostic  error: 

It   cannot  be   too   strongly   emphasized   that  there   is   no 


CARCINOMA  OF  THE  STOMACH.  725 

cancer  age.  While  cancer  is  more  common  in  the  years 
between  40  and  70,  with  the  gastric  incidence  occurring  in 
the  sixth  decade,  nevertheless,  cancer  may,  and  frequently 
does,  appear  in  the  early  period  of  life ;  and  in  Smithies'  series 
of  921  cases,  largely  collected  from  the  Mayo  clinics,  10  cases 
were  under  30,  and  1  died  at  the  age  of  19.  As  regards  race 
and  nationality  cancer  is  ubiquitous. 

There  are  no  occupations  that  really  predispose  to  gastric 
cancer,  but  it  seems  to  be  more  common  among  those  who 
are  more  prosperous.  In  this  regard  Williams  has  noted 
that  Ireland,  with  its  rug"ged  life  and  underfed  people,  has  a 
much  lower  cancer  death-rate  than  England,  where  prosperity 
is  at  a  higher  level,  and  similarly  Hoffman, 21  in  a  study  of 
life-insurance  statistics,  has  shown  that  the  mortality  from 
cancer  is  much  less  among  wage-earners  than  among  well- 
to-do  people. 

There  seems  to  be  no  particular  kind  of  food-overindul- 
gence which  will  predispose  to  cancer.  Probably  habitual 
overloading  of  the  stomach,  together  with  insufficient  masti- 
cation, tends  far  more  to  the  production  of  gastric  cancer  than 
does  the  type  of  food  ingested.  From  Smithies'  statistics, 
alcohol  seems  to  play  but  a  small  part,  whereas  tobacco  may 
be  a  more  active  etiologic  factor,  15  per  cent,  of  Smithies'  cases 
being  excessive  smokers. 

There  does  seem  to  be  a  proved  connection  between  exter- 
nal abdominal  trauma  and  the  development  of  gastric-cancer 
symptoms,  but  it  is  more  probable  that  the  external  injury 
may  have  caused  an  acceleration  in  a  latent  malignant  process, 
r-ather  than  actually  to  have  produced  it.  In  addition  to  exter- 
nal .abdominal  injury,  internal  traumatic  influences  may  be 
mechanical,  chemical,  biochemical,  or  parasitic,  and  evidence 
is  accumulating  that  in  certain  cases  each  of  these  factors  may 
predispose  to  gastric  cancer.  In  regard  to  ingested  parasites 
it  is  interesting  to  note  the  investigations  of  Febiger,--  of 
Copenhagen,  who  found  that  certain  laboratory  rats  were 
dying  of  cancer-like  tumors  of  the  stomach,  and  on  examina- 
tion he  found  that  many  of  these  tumors  contained  encysted 
nematodes.  Febiger  ascertained  that  these  rats  were  largely 
secured  from  a  certain  sugar  refinery  that  was  infested  with 
roaches.     Examination  of  these  roaches  showed  them  to  con- 


726  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

tain  worms.  Febiger  then  collected  large  numbers  of  these 
roaches,  and  fed  them  to  uninfected  laboratory  rats,  and  noted 
the  development  of  cancer-like  growths  in  the  stomach  of 
many  of  them.  Commenting  upon  this,  Smithies  states : 
"While  there  is  some  doubt  of  the  true  carcinomatous  nature 
of  Febiger's  rat  ttimors,  the  investigation  is  of  value  in  show- 
ing the  reaction  of  gastric  mucosa  to  a  parasitic  irritant.  It 
also  shows  the  histologic  difficulties  of  differentiating  hyper- 
plasia of  a  granulomatous  type  from  the  hyperplasia  of  true 
malignancy." 

Heredity  is  a  less  important  factor  than  we  have  been  led 
to  believe,  occurring  in  only  5  per  cent,  of  Smithies'  921  cases, 
although  there  are  on  record  many  well-known  gastric-cancer 
families  which  have  contributed  the  greatest  amount  of  sub- 
stantiation to  our  earlier  beliefs.  It  would  seem  that  there  is 
a  greater  tendency  of  hereditary  transmission  of  cancer  of  the 
uterus  and  mammary  glands  than  of  the  t\'pe  afifecting  the 
stomach. 

Oral  sepsis,  undoubtedly,  plays  a  large  role  in  the  estab- 
lishment of  gastric  disorder,  notably  ulcer,  and  Smithies  states 
that  "gastric  cancer  and  filthy  mouths  go  hand  in  hand." 

From  the  exceptional  work  of  MacCarty  and  Wilson  in  the 
Mayo  clinic  we  now  know  that  chronic  gastric  ulcer  is  the 
most  frequent  disposing  factor  to  gastric  cancer,  although 
many  surgeons  and  clinicians  affirm  that  the  statistics  of  these 
workers  are  too  extravagant  in  their  association  of  carcino- 
matous degeneration  with  chronic  calloused  gastric  ulcers,  or 
the  microscopic  beginning  of  earl}'-  gastric  cancer  in  the  imme- 
diate neighborhood  of  chronic  ulcers.  s- 

The  other  gastric  condition  that  may  be  a  predisposing 
factor  of  cancer  is  the  group  of  achylias,  associated  with  the 
primar}^  anemias,  oral  sepsis,  intestinal  autointoxication,  and, 
less  commonly,  cholelithiasis.  These  achylias,  which  are  re- 
garded as  benign,  owing  to  their  compatibility  with  years  of 
good  health,  ultimately  for  no  demonstrable  reason  become 
cancerous.  Ewald,  and  particularly  AVolfi",  of  the  Augusta 
Hospital  in  Berlin,  personally  emphasized  to  the  writer  the 
fact  that  they  have  watched  certain  benign  achylias  of  sev- 
eral years'  duration  develop  gradually  into  the  malignant 
type,  when  checked  by  WolfT's   soluble-albumin  test,23   and 


Carcinoma  of  the  stomach.  727 

ultimately  confirmed  by  operation,  and  Wolff  contended  tliat 
such  observations  in  the  future  would  be  more  commonly 
recorded. 

Gastric  cancer  is  very  frequently  secondary  to  extragastric 
cancer,  either  by  direct  continuity  of  neighborhood  viscera 
(liver,  gall-bladder,  pancreas  and  transverse  colon),  or  by 
metastases  by  way  of  the  lymph-channels  from  cancers  of  the 
breast,  uterus  or  prostate. 

Gastric  cancer  is  a  neoplasm  having  its  microscopic  begin- 
ning in  atypical  gastric  epithelium,  which  shows  a  tendency 
to  invade  the  surrounding  tissues.  Smithies  has  aptly  stated 
that  no  one  has  ever  histologically  observed  the  earliest 
beginnings  of  any  malignant  process  in  human  beings,  nor 
'has  gastric  cancer  ever  been  experimentally  produced  in 
human  beings.  Therefore,  we  are  left  in  ignorance  regarding 
the  early  morbid  histology.  In  many  lower  animals,  and  in 
many  plants  the  experimental  production  of  cancer  has  been 
successfully  accomplished,  and  Smithies  says  that  "it  is  now 
generally  accepted  'that  early  malignant  processes  are  in  the 
nature  of  hyperplasia  of  already  existing  structural  elements, 
.  .  .  .  that  a  tissue  reaction  takes  place  which  results  in 
undifferentiated  growths  of  a  particular  cell  group,  .... 
and  that  commonly  the  specific  function  of  the  cells  is  lost." 

Just  what  determines  the  beginnings  of  these  cellular  and 
intracellular  deviations  we  do  not  know.  They  may  be 
responses  to  irritants  of  various  kinds,  plus  an  inherent  or 
acquired  susceptibility  of  individual  cells  to  be  metabolically 
or  histologically  disturbed.  We  do  know,  how^ever,  that  when 
the  same  irritant  is  experimentally  introduced  into  different 
hosts,  it  frequently  gives  rise  to  cellular  changes  which  may 
vary  markedly. 

The  prognosis  in  any  given  cancer  case  depends  largely 
upon  the  following  points :  the  rate  of  abnormal  proliferation 
of  cell  groups,  the  direction  of  their  proliferation,  the  rate  of 
their  metastases,  as  represented  by  their  accessibility  to  the 
lymph-channels ;  the  effect  such  epithelial  cells  have  upon  the 
adjacent  tubules  in  the  production  of  retrograde  changes;  and 
complications,  such  as  obstructions  of  the  orifices  of  the 
stomach,  contraction  deformities  of  the  stomach,  hemorrhage 
and  perforations. 


728  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

Pathologically,  carcinoma  of  the  stomach  may  be  divided 
into  the  following  types :  medullary,  scirrhous,  colloid  and 
the  ulcus  carcinomatosum.  While  all  of  these  types  are 
fundamentally  of  epithelium  derivation,  yet  the  rate  of  their 
growth  varies  widely.  ^Medullary  and  colloid  cancers  advance 
much  more  rapidly  than  the  scirrhous  variety,  seemingly 
influenced  somewhat  b}'  the  state  of  nutrition  of  the  individ- 
ual, lean,  spare,  sallow  patients  appearing  to  tolerate  cancer 
toxins  better  than  do  their  more  robust  brothers.  So,  too, 
the  location  of  the  neoplasm  governs  its  rate  of  growth,  which 
is  particularly  rapid  when  it  affects  the  cardia  and  the  pylorus. 

Cancer  of  the  stomach  is  most  likely  to  implicate  the 
pylorus  and  upper  curvature,  and  nearly  all  groups  of  sta- 
tistics show  about  60  per  cent,  of  such  a  location.  Cancers 
of  the  general  stomach,  of  the  posterior  wall,  the  cardia,  the 
greater  curvature  and  the  anterior  wall,  occur  with  decreas- 
ing frequency  in  the  above  order,  while  cancers  of  the  fundus 
are  least  common  of  all. 

]\Ietastases  control  the  prognosis,  entirely  irrespective  of 
the  size  or  rate  of  growth  of  the  primary  tumor  in  a  given 
case,  and  the  outlook,  is  determined  by  the  direction  and 
extent  of  the  lymph-gland  invasion.  The  perigastric  glands 
are  commonh-  aft"ected  first,  and  next  most  frequently  Vir- 
chow's  gland,  the  left  supraclavicular,  this  probably  being- 
due  to  the  fact  that  the  thoracic  duct  empties  into  the  left 
subclavian  vein  at  this  point.  Other  important  complications 
are  those  due  to  obstruction  involving  the  pylorus  or  the 
-Cardia,  malignant  hour  -glass  constriction,  hemorrhage  and 
perforation. 

Diagnosis  and  Symptomatology,  In  cancer  of  the  stomach 
the  most  valuable  diagnostic  data  may  be  obtained  |)y  the 
intelligent  taking  of  the  history,  and  the  interpretation  of 
these  historical  facts.  It  is  not  onh-  the  histor}-  of  the  present 
illness  that  concerns  us,  but  a  close  inquiiy  into  the  presence 
or  absence  of  symptoms  of  abnormal  digestion  that  ma^^  have 
occurred  for  many  years.  A\'e  have  learned  that  there  is  quite 
frequentlv  a  common  sequence  of  events.  Ideally  the  time  to 
diagnose  our  gastric  cancers  is  in  their  precancerous  stage, 
and  this  can  be  most  successfully  carried  out  if  we  recognize 
that  exery  gastric-ulcer  history,  especially  if  of  long  duration. 


CARCINOMA  OF  THE  STOMACH.  729 

is  potentially  that  of  cancer.  The  symptomatology  of  this 
precancerous  stage  is  essentially  the  same  as  that  which  com- 
monly fulfills  the  accepted  clinical  requirements  of  gastric 
ulcer.  There  is  a  history  of  intermittent  symptoms,  with 
acute  periodic  exacerbations  and  equally  sudden  remissions 
of  many  weeks  or  months.  The  pain  is  of  a  boring,  gnawing, 
sometimes  burning,  rarely  colicky  type  (if  associated  with 
pylorospasm),  and  occurs  one  to  two  hours  after  eating,  but 
the  time  varies  according  to  the  location  of  the  ulcer  and  the 
amount  and  quality  of  the  food.  Furthermire,  the  pain  is 
relieved  by  additional  food-taking;  or,  by  the  administration 
of  alkalies,  and  by  lavage.  Exacerbation  of  pain  during  the 
early-morning  slumber  hours  is  not  infrequent.  Vomiting  is 
a  common  and  most  important  symptom,  and  its  type  and 
time  will  vary  according  to  the  proximity  of  the  ulcer  to  the 
gastric  orifices,  to  the  amount  of  cicatricial  contraction,  and 
to  the  amount  of  periulcerous  inflammatory  edema  and  con- 
gestion.    This  is  the  precancerous  stage. 

Carcinomatous  degeneration  around  the  edges  and  at  the 
base  of  the  ulcer  may  have  taken  place  weeks  and  months 
before  clinical  symptoms  of  malignancy  appear,  and  now  the 
picture  changes.  The  symptoms  become  continuous  rather 
than  intermittent;  there  may  be  no  actual  pain,  but  rather  a 
sense  of  epigastric  weight  and  discomfort.  If  pain  be  present 
it  is  usually  constant;  it  is  often  of  a  dull-aching  character, 
and  shows  much  less  tendency  to  food  and  medicinal  relief; 
the  appetite  and  nutrition,  normally  so  well  preserved  in  ulcer, 
may  now  begin  to  be  affected;  weight  loss  may  be  compara- 
tively rapid,  and  is  seemingly  greater  in  the  younger  and 
more  robust,  and  finally  a  degree  of  cachexia  may  be  reached 
similar  to  that  seen  in  the  type  of  gastric  cancer  about  to  be 
described. 

This  type  is  the  one  that  makes  up  the  common  textbook 
history  of  gastric  cancer.  It  occurs  usually  at  a  later  age 
period  than  that  just  described.  In  these  patients  we  may 
have  no  history  of  pre-existing  gastric  disturbance.  They  tell 
us  that  until  the  onset  of  symptoms  they  never  knew  they 
possessed  a  stomach ;  that  they  could  "digest  wire-nails  with- 
out distress,"  until  suddenly,  sometimes  insidiously,  they  may 
become  conscious  of  failure  in  appetite,  with  various   aver- 


730  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

sions  to  formerly  well-liked  foods,  such  as  meats  and  sweets, 
and  vague  epigastric  distress  after  meals  may  occur.  At  first 
this  distress  may  be  merely  a  sensation  of  epigastric  pressure 
and  heaviness  followed  by  belching,  with  later  sour  regurgi- 
tations or  water-brash.  Pain  may,  or  may  not,  be  present, 
but  it  is  usually  of  a  dull-aching  character,  at  first  periodic 
and  later  continuous,  depending  largety  upon  the  amount  of 
food  retention.  Gradual  progressive  loss  of  weight  and 
strength  appears  early,  and  its  degree  bears  a  relation  to 
individual  tolerance  of  cancer  toxins  on  the  one  hand,  and  on 
the  other  hand  to  the  situation  of  the  cancer  in  relation  to 
obstruction  of  the  gastric  orifices.  Inasmuch  as  the  com- 
monest location  affects  the  pylorus,  obstructive  symptoms 
appear  relatively  early,  except  in  those  rarer  types  of  scir- 
rhous cancer  of  the  leather-bottle  type,  with  rigid  gastric 
walls  and  patent  pylorus.  AMien  obstruction  occurs  vomiting 
becomes  more  common,  and  as  the  stomach  dilates  the  vomit- 
ing gradually  assumes  the  retention  type.  The  vomitus  may 
be  odorless,  but  usually  it  is  sour  or  rancid,  and  later  becomes 
chees}'  or  putrid,  according  to  the  amount  of  cancer  slough. 
It  may  be  of  an}-  color,  and  if  we  wait  for  the  classic  coffee- 
ground  t3'pe  to  appear,  the  case  is  usually  inoperable.  Diar- 
rhea, of  sudden  onset  and  equalh'  sudden  cessation,  may 
often  be  noted.  Graduall}-  the  picture  advances  to  that  of 
profound  cachexia  with  mental  depression,  often  melancholia, 
with  a  palpable  gastric  tumor  and  enlargement  of  the  super- 
ficial lymphatic  glands.    The  condition  is  surgicalh-  hopeless. 

It  is  not  the  writer's  purpose  to  discuss  in  detail  the  pos- 
sible information  to  be  obtained  from  physical  examination. 
In  early  primary  malignanc}-  there  are  no  pathognomonic 
findings.  In  cancer  associated  with  gastric  ulcer  the  physical 
findings  are  those  of  the  latter.  When  cancer  is  well  estab- 
lished the  diagnosis  can  almost  be  made  from  the  foot  of  the 
bed  by  casual  inspection.  It  might  be  well  to  mention  the 
seven  signs  of  inoperability  of  gastric  cancers  as  tabulated  by 
Smithies.    They  are : 

1.  Evidence  of  gland  enlargement  above  the  left  clavicle. 

2.  Invasion  of  Blumer's  rectal  shelf. 

3.  Metastasis  to  the  umbilicus. 

4.  Local  or  general  increase  in  the  size  of  the  liver. 


CARCINOMA  OF  THE  STOMACH.  731 

5.  The  presence  of  free  peritoneal  fluid. 

6.  Enlargement  of  inguinal  lymph-nodes. 

7 .  Palpable  lymphatic  metastases  about  the  pylorus  or 
along  the  lesser  curvature. 

In  all  cases,  whether  early  or  late,  a  thorough  and  com- 
plete physical  examination  is  to  be  made,  supplemented  by 
detailed  laboratory  and  rontgen-ray  examination.  No  exami- 
nation is  complete  without  the  use  of  the  stomach-tube,  and 
in  few  gastric  conditions  can  so  much  important  informa- 
tion be  obtained.  The  empty  stomach  contents  should  be 
examined,  and  motor  and  secretory  tests  made.  Every  prac- 
titioner should  train  himself  in  carrying  out  these  measures, 
should  be  able  to  interpret  his  results  intelligently,  and  to 
properly  weigh  the  diagnostic  data.  His  office  laboratory 
should  be  adequately  equipped  with  reliable  reagents  to  carry 
through  most  of  the  necessary  tests,  and  sufficiently  used  to 
insure  the  saving  in  time  by  being  familiar  with  technical 
methods.  It  is  amazing  the  amount  of  laboratory  work  that 
even  the  busy  average  doctor  can  accomplish,  if  only  he  will 
do  so.     Daily  practise  makes  perfect. 

The  methods  of  diagnostic  procedure  will  vary  somewhat 
in  individual  cases,  but  the  following  routine  will  answer  for 
the  most:  The  day  before  the  patient's  gastric  analyses  are 
to  be  made  it  is  wise  to  have  him  take  an  ounce  of  castor  oil 
at  3  or  4  o'clock  in  the  afternoon.  At  9  o'clock  that  night  his 
dinner  should  be  eaten,  and  may  consist  of  any  mixed  meal 
containing  meat,  vegetables,  particularly  spinach  or  rice,  and 
salad.  At  10  o'clock  about  twenty  seedless  raisins  should  be 
eaten  with  their  skins.  The  following  morning,  at  a  time 
varying  from  7  to  9  a.m.,  a  large-size  stomach-tube  should 
be  passed,  and  the  ten-  or  twelve-  hour  fasting  stomach 
should  be  aspirated,  the  total  amount  recovered  being  meas- 
ured and  saved.  By  means  of  a  2-  or  3-  ounce  (60  or  90  mils) 
glass  syringe  about  300  mils  (10  ozs.)  of  warm  water  are  intro- 
duced into  the  stomach,  and  reaspirated  several  times,  so.  that 
the  mucous  membrane  is  gently  flushed  and  the  returning 
fluid  contains  small  macroscopic  flocculent  particles.  The 
total  amount  of  fluid  aspirated,  vv^hich  averages  150  mils  (5 
ozs.),  is  allowed  to  settle  for  a  few  moments  in  a  conical  ves- 
sel.    The  supernatant  excess  fluid  is  then  poured  ofif;  a  por- 


732  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

tion  of  the  sediment  is  pipetted  oft  for  a  separate  examina- 
tion, and  the  remainder  is  added  to  an  equal  amount  of  20 
per  cent,  formahn.  This  sediment  is  then  hardened  by  the 
usual  methods,  and  paraffin-block  sections  are  made  and  dif- 
ferentially stained.-"^  This  method  of  obtaining-  gastric  sedi- 
ments, with  their  subsequent  microscopic  study  under  all 
magnifications,  may  alone  be  sufficient  to  establish  a  positive 
diagnosis  in  man}-  cancer  cases.  AA'hile  the  stomach  is  being 
rinsed  by  the  above  syringe  method  in  the  hands  of  an 
assistant,  or  even  by  the  patient  himself,  auscultation  and 
bimanual  palpation  of 'the  gastric  area  and  the  left  back  can 
be  quickl)'  carried  on  in  various  positions,  and  the  size,  shape, 
position,  and  relative  mobilit}-  of  the  stomach  may  be  quickly 
ascertained.  The  tube  is  then  -withdrawn,  and  a  secretory 
test-meal  of  50  grams  (1.607  oz.)  of  bread  with  350  mils 
(11.066  ozs.)  of  water  should  be  given  and  withdrawn  fifty  or 
sixty  minutes  later,  b}-  either  the  large  or  the  small  tube 
method.  If  time  will  permit,  fractional  analyses  should 
preferably  be  made,  and  should  always  include  fractional 
analyses  for  soluble  albumin  (Wolfif-Junghan's  reaction)  to 
differentiate  benign  and  malignant  aclwlias. 

All  the  materials  extracted  from  the  stomach  should  be 
measured,  and  the  following  points  noted :  the  color,  the 
odor,  the  relative  proportion  of  residue  and  filtrate,  the  pres- 
ence and  amount  of  mucus,  and  macroscopic  evidence  of  blood 
and  bile. 

Microscopic  examinations  should  be  carried  out  both  in 
the  unstained  state  and  b}^  the  colored  agar  method,  together 
with  iodine  and  osmic  acid  preparation  for  the  determination 
of  food-rests.  For  its  main  objects  the  examination  should 
determine  the  evidence  of  peptic  digestion  (digested  proto- 
plasm), the  presence  of  cellular  elements  (epithelium,  leuco- 
cytes, erythrocytes),  hemin  crx'stals,  germinating  yeast  cells, 
sarcinae,  Oppler-Boas  bacilli,  and  other  bacterial  floras. 

Food-rests  from  a  twelve-hour  fasting  stomach,  when 
macroscopic,  are  almost  invariabh-  indicative  of  pyloric  ob- 
struction, and  to  a  less  extent  when  found  microscopically. 
It  mav  be  necessary,  however,  to  repeat  motor  tests  to  be 
extracted  at  six-  and  eight-  hour  inter\'als,  to  detect  lesser 
grades  of  motor  insufficiency.     The  following  chemical   an- 


CARCINOMA  OF  THE  STOMACH.  733 

anlyses  should  be  made  :  Tlie  amount  of  free  and  combined 
hydrochloric  acid,  the  total  acidity,  the  presence  of  associated 
organic  acids,  particularly  lactic  acid,  and  to  a  less  extent 
butyric  and  acetic,  and  chemical  tests  for  the  determination 
of  the  activity  of  the  gastric  enzymes.  The  Gluzinski  method 
of  testing-  the  gastric  secretory  response  in  the  production  of 
varying  acidities  to  different  test-meals  is  one  of  considerable 
aid  in  differentiating  uncomplicated  gastric  ulcer  from  one 
undergoing  carcinomatous  degeneration. 

While  there  are  as  yet  no  pathognomonic  chemical  or 
biologic  tests  for  cancer,  and  while  those  thus  far  developed 
when  positive  only  support  the  diagnosis  of  a  cancer  well 
established,  nevertheless,  it  may  be  well  to  give  a  brief  resume 
of  such  of  them  as  give  the  most  reliable  information.  One 
of  the  best  is  the  Wolff-Junghan  reaction  for  the  determina- 
tion of  soluble  albumin,  which  is  generally  increased  in  cancer 
cases,  either  from  albuminous  absorption,  from  the  presence 
of  cancer-juice  rich  in  albumin,  or  from  the  presence  of  a 
specific  cancer-ferment  which  can  carry  proteid  digestion  to 
the  final  stage  of  soluble  albumin.  By  this  test  the  obtain- 
ing of  200  to  400,  or  more,  units  of  soluble  albumin  is  sup- 
portive of  a  cancer  diagnosis.  It  is  positive  in  about  80  per 
cent,  of  cases.  The  so-called  "peptic  index,"  by  means  of  the 
Edestin  test  of  Fuld  and  Levinson,^^  is  sometimes  helpful,  in- 
asmuch as  it  has  been  shown  that  cases  of  carcinoma  with  low 
free  hydrochloric  acid  readings  exhibit  high  peptolysis  and  low 
proteolysis,  whereas  benign  peptic  ulcers  with  low  hydro- 
chloric acid  give  low  readings  for  both  peptolysis  and  pro- 
teolysis. Again,  the  "formol  index,"  suggested  by  Schryver 
and.Singer26  for  the  detection  of  specific  ereptases  in  gastric 
juice,  and  modified  by  Sorenson  and  Schiff,^"  also  is  a  good 
differential  test,  inasmuch  as  primary  gastric  cancer  and  ulcus 
carcinomatosum  furnish  a  high  formol  index,  averaging  20 
to  22,  whereas  benign  gastric  and  duodenal  ulcers,  benign 
achylia  gastrica,  and  that  associated  with  pernicious  anemia 
give  average  readings  from  10  to  14.  The  glycyltryptophan 
test  of  Neubauer  and  Fischer,28  and  the  modified  tryptophan 
test  of  Weinstein,29  are  less  important  than  those  already  men- 
tioned. 

Space  does  not  permit  a  consideration  of  the  examination 


734  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

of  the  stool,  except  to  emphasize  the  importance  of  determin- 
ing the  presence  of  altered  blood  by  the  use  of  the  benzidine 
test  for  exclusion,  checked  by  the  guaiac  test  for  provement. 
To  be  carried  out  properly  the  patient  should  be  kept  on  a 
vegetarian  diet  for  several  days,  and  on  a  milk  diet  for  twenty- 
four  hours,  and  the  second  stool  obtained  after  this  should 
be  tested. 

While  emphasizing  the  fact  that  such  findings,  unfortu- 
nately, rarely  make  for  early  diagnosis,  the  writer  briefly  sum- 
marizes the  laboratory  points  most  valuable  in  support  of  a 
diagnosis  of  gastric  cancer : 

1.  Evidence  of  pyloric  obstruction  from  the  motor  test- 
meals. 

2.  Evidence  from  secretory  test-meals  of  a  lowered  hydro- 
chloric acid  output.  (While  this  varies  so  greatly  that  one 
may  expect  to  see  all  types  of  a  normal  or  altered  acidity, 
nevertheless,  a  lowered  or  absent  free  hydrochloric  acid  is 
suggestive,  especially  in  the  presence  of  a  foreign  acid,  partic- 
ularly lactic.) 

3.  The  demonstration  of  Oppler-Boas  bacilli  in  connection 
with  positive  or  suspicious  gastric  sediment  pictures. 

4.  A  WoliT-Junghan  reaction  above  200-  units. 

5.  A  high  formol  index. 

6.  A  high  degree  of  peptolysis  by  means  of  the  Edestin 
test. 

7.  The  presence  of  occult  blood  in  the  gastric  filtrate  and 
stool  extracts. 

These  singly  or  in  combination  are  often  more  than  suffi- 
cient evidence,  but  frequently  they  are  obtained  too  late  to 
be  of  much  practical  service  to  the  patient. 

The  prognosis  of  gastric  cancer  depends  mainly  upon  three 
factors : 

1.  How  early  the  patient  reports  for  medical  examination. 

2.  On  our  ability  to  make  an  early  diagnosis  obtained  from 
a  searching  anamnesis,  careful  physical  examination,  and  the 
use  of  technical  diagnostic  tests. 

3.  Early  operation  and  the  ability  of  the  surgeon  mechanic- 
ally to  cope  successfully  with  the  conditions  found  on  the 
operating  table. 


CARCINOMA  OF  THE  STOMACH  735 

TREATMENT. 

The  treatment  of  gastric  cancer  is  entirely  a  surgical  prob- 
lem, except  in  such  cases  as  prove  inoperable.  This  is  no 
field  for  the  occasional  surgeon.  The  writer  believes  in  select- 
ing a  surgeon  of  long  experience,  with  a  sound  surgical  judg- 
ment of  what  can  be  done,  what  ought  to  be  done,  and  what 
should  not  be  attempted,  a  judgment  that  has  been  ripened  by 
experience  in  daily  operating,  and  particularly  a  surgeon  who 
is  interested  in  gastrointestinal  problems,  or  in  those  of  the 
upper  abdominal  zones. 

Surgical  Treatment  of  Cancer.  There  are  five  types  of 
operations  that  are  commonly  done  in  the  surgical  treatment 
of  gastric  cancer.  Taken  in  the  order  of  their  frequency  they 
will  be  discussed  as  follows : 

1.  Exploratory  Laparotomy.  This  operation  should  be 
heartily  encouraged  in  cases  suspected  of  gastric  cancer  when 
such  have  been  properly  studied  from  a  historical,  laboratory 
and  rontgen-ray  standpoint.  Indeed,  in  many  communities 
when  advanced  diagnosis  is  not  obtainable,  an  early  ex- 
ploratory laparotomy  best  serves  the  interest  of  the  patient. 
Where  the  possibility  of  cancer  is  concerned  the  writer 
unequivocally  indorses  exploratory  laparotomy  as  a  means  to 
a  final  diagnosis,  just  as  strongly  as  he  condemns  the  too  pre- 
valent custom  of  exploratory  laparotomy  for  the  diagnosis  of 
abdominal  conditions  that  should  be  made  non-surgically,  if 
the  patient  is  sufficiently  and  carefully  studied,  and  in  whom 
the  stake  of  life  or  death  is  not  unduly  hazarded  by  the  delay 
of  a  few  weeks.  But  where  cancer  is  a  diagnostic  presump- 
tion, exploratory  laparotomy  is  thoroughly  justifiable,  and  the 
earlier  it  is  done  the  better,  for  by  this  means  alone  can  the 
percentage  of  surgical  cures  be  g-reatly  improved,  and  the 
immediate  or  remote  operative  mortality  lessened. 

It  is,  as  a  rule,  neither  wise  to  tell  the  patient  that  gastric 
malignancy  is  suspected,  nor  to  enter  too  closely  with  him 
into  a  difl:erential  discussion  of  his  symptoms,  inasmuch  as 
apparent  lack  of  certainty  on  the  part  of  the  diagnostician  may 
cause  a  corresponding-  lack  of  confidence  in  the  patient  suffi- 
cient to  cause  him  to  postpone  operative  interference.  A\'hile 
this  is  the  rule,  there  are  some  patients  l^efore  whom  the  facts 


736  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

in  their  case  may  be  fully  outlined  without  shaking  their 
belief  that  laparotomy  is  the  wisest  course,  and  without  break- 
ing down  their  courage  and  fighting  spirit,  should  a  cancer 
diagnosis  be  confirmed.  In  any  event,  some  sensible  member 
of  the  family  or  some  reliable  friend  should  be  taken  fully 
into  confidence  as  to  just  what  the  diagnostic  dilemma  is,  and 
why  diagnosis  by  means  of  sight  and  touch  in  many  cases  is 
more  reliable  than  the  best  of  the  laboratory  maneuvers.  In 
the  hands  of  the  capable  surgeon  of  wide  experience,  often  as 
well  or  better  versed  in  gross  and  living  pathology  than  is  the 
laboratory,  expert,  what  the  exploratory  laparotomy  discloses 
will  determine  the  best  operative  procedure  to  follow.  This 
will  concern  itself  with  one  of  the  following  operations  or  a 
combination  of  them. 

2.  Resection  of  the  Cancer-bearing  Area.  This,  the  ideal 
operation,  is  often  the  most  radical  one,  and,  although  it  bears 
a  higher  immediate  operative  mortality,  it  insures  the  best 
and  most  enduring  end-results  in  successful  cases.  In  all 
ulcers  on  the  gastric  side  of  or  at  the  pylorus,  wide  excision 
of  the  ulcer-bearing  area  offers  the  best  preventive  measure 
of  gastric  cancer,  and  the  cure  of  incipient  malignancy.  In 
cases  of  gastric  tumor  of  a  carcinomatous  type  localized  at 
or  near  the  pylorus,  with  or  without  early  implication  of  the 
perigastric  glands,  as  wide  a  resection  should  be  practised  as 
is  compatible  with  the  surgical  mechanics  involved.  Resec- 
tion of  one-third,  or  even  one-half,  of  the  stomach  has  been 
successfully  carried  out  in  a  few  cases,  and  either  the  con- 
tinuity of  the  gastric  lumen  maintained  by  an  end-to-end 
anastomosis,  or  a  gastrojejunostomy  performed  for  proper 
drainage.  It  is  to  be  hoped  that,  as  our  diagnostic  efficiency 
and  our  operative  skill  increases,  a  larger  majority  of  our 
patients  may  be  found  in  whom  the  radical  cure  for  gastric 
cancer  may  be  successfully  attempted.  However,  the  hope  for 
this  lies,  to  a  great  extent,  in  the  hearty  and  sincere  co-opera- 
tion between  the  operating  surgeon  and  the  clinician,  for  it 
frequently  happens  that  the  latter,  who  has  studied  the  case 
with  painstaking  care  and  minuteness,  and  in  whom  explora- 
tory laparotomy  discloses  an  indurated  chronic  ulcer,  which 
no  man,  by  sight  or  touch,  can  declare  is  or  is  not  cancer  in 
its  incipient  stage,  is  met  with  a  disinclination  on  the  part  of 


CARCINOMA  OF  THE  STOMACH.  737 

the  surgeon  to  shoulder  the  increased  operative  responsilMlity 
of  a  radical  resection.  This  atitude  is  to  be  strongly  depre- 
cated, and  will  be  largely  prevented  as  the  operator  gets  far- 
ther away  from  the  old  standards  of  the  "barber-surgeon," 
and  studies  each  case  with  the  closer  scrutiny  of  the  clinician. 
In  such  border-line  cases  as  just  cited,  the  field  of  rapid  micro- 
scopic diagnosis,  by  means  of  frozen  section  studies,  is  just 
beginning  to  be  practised  outside  of  our  larger  surgical  clinics, 
and,  when  capably  carried  out,  may  definitely  settle  such  a 
diagnostic  dispute. 

The  physician  should  make  it  a  point  to  be  present  at  all 
operations  of  patients  he  has  studied,  and  if  proper  team-work 
is  to  be  carried  out  he  should  be  surgically  clean,-  properly 
gowned  and  gloved,  so  that  he  can  add  the  weight  of  his 
opinion,  after  personal  sight  and  touch  of  the  disease-bearing 
area,  as  to  what  surgical  procedure  should  be  attempted. 

3.  Gastroenterostomy .  With  or  without  partial  resection, 
this  is  the  commonest  of  all  the  palliative  operations  in  the 
surgical  treatment  of  gastric  cancer.  While  not  in  any  sense 
curative,  it  frequently  prolongs  life  for  many  months,  and 
even  for  a  few  years,  during  which  time  the  patient  enjoys 
marked  symptomatic  improvement.  Indeed,  in  some  instances 
the  restoration  to  an  appearance  of  health  is  so  marked  as  to 
make  one  feel  that  a  mistake  in  diagnosis  may  have  been 
made,  but  sooner  or  later  the  advancing  evidences  of  cachexia 
appear,  and  the  subsequent  march  to  the  coffin  is  rapid.  Gas- 
troenterostomy is  always  indicated  where  motor  obstruction 
affecting  the  pylorus  is  apparent.  It  is  needless  to  say  that 
the  state  of  gastric  motility  by  means  of  motor  test-meals, 
supplemented  by  ,r-ray  examinations,  should  be  adequately 
determined  before  the  exploratory  laparotomy.  While,  the- 
oretically, partial  resection  of  a  putrid,  sloughing,  inoperable 
gastric  cancer  may,  be  indicated  when  combined  with  gastro- 
enterostomy, on  the  grounds  that  it  may  partly  arrest  the 
absorption  of  toxins  from  this  local  source,  nevertheless,  it 
appears  to  the  writer  that  in  cases  he  has  seen  so  treated 
much  more  metastatic  invasion  has  taken  place  by  way  of  the 
newly  opened  vascular  and  lymphatic  channels,  and  it  would 
seem  wiser  to  get  rid  of  such  cancer  toxins  by  means  of  fre- 
quent lavage  with  antiseptic  solutions. 

47 


738  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

4,  Gastrostomy.  This  palliative  operation  is  indicated  in 
cases  in  which  the  cancer  invades  the  cardiac  end  of  the 
stomach  and  prevents  the  passage  of  food  by  way  of  the 
g-uUet.  By  this  means  patients  may  be  kept  alive  for  several 
months,  by  direct  feeding  through  the  gastric  fistula,  although 
it  often  makes  the  patient's  postoperative  life  more  unbear- 
able, and  in  the  writer's  opinion  is  against  the  principles  of 
euthanasia, 

5.  Jejunostomy  has  been  frequently  performed  as  a  sub- 
stitute for  gastroenterostomy  in  greatly  debilitated  patients, 
on  account  of  the  rapidity  of  the  operative  procedure  and  the 
minimal  degree  of  subsequent  surgical  shock.  It  has,  how- 
ever, the  same  disadvantages  that  are  associated  with  gas- 
trostomy, and  prolongs  the  patient's  life  for  but  a  brief  period. 

Medical  Treatment  o£  Cancer.  For  those  poor  sufferers 
with  inoperable  cancer  much  may  be  done  to  make  them  more 
comfortable,  although  it  may  tax  our  resources  to  the  utmost 
to  accomplish  such  ends. 

After  an  exploratory  operation  has  been  done,  and  the 
surgical  verdict  of  inoperable  cancer  given,  or  when  the 
attempt  at  radical  resection  has  failed,  and  it  becomes  evident 
that  there  is  local  or  metastatic  recurrence,  and  when  all 
palliative  operative  measures  have  been  exhausted,  the  sur- 
geon usually  passes  the  after-treatment  over  to  the  physician, 
and  is  glad  to  wash  his  hands  of  further  responsibility.  To 
many  a  physician  the  medical  handling  of  such  incurable 
cases  is  often  repugnant,  many  lose  interest  in  the  constant 
daily  rehearsal  of  symptoms  by  the  chronic  and  helpless 
invalid,  together  with  the  importuning  of  members  of  the 
family  that  something  must  be  done.  In  such  instances  nat- 
urally it  is  often  the  sincere  wish  of  the  doctor  that  he  might 
be  allowed  to  hasten  the  coming  of  a  speed}^  and  painless 
death.  But  as  long  as  we  have  our  laws  prohibiting  the  prac- 
tice of  euthanasia,  and  as  long  as  our  medical  ethics  are  as 
they  are,  it  becomes  our  manifest  duty  to  prolong  life  to  the 
utmost,  and  at  the  same  time  to  make  the  voyage  across  the 
River  Styx  as  easy  and  painless  as  possible.  This  requires 
patient  persistence,  tactfulness,  cheeriness,  and  the  constant 
instilling  of  courage  to  the  very  end.  As:  already  said,  much 
may  be  done  to  alleviate  unnecessary  suffering,  and  the  means 


CARCINOMA  OF  TITK  STOMACH.  739 

rit  our  disposal  may  he  !:;r()uped  under  four  headini^s :  general 
hygiene,  mechanical,  dietetic,  and  medicinal  measures. 

Hygiene.  What  has  been  said  at  length  in  the  chapter  on 
the  treatment  of  ulcer  in  regard  to  hygiene,  and  the  care  of 
the  mouth  and  its  contents  need  not  be  recapitulated  here, 
except  to  again  emphasize  the  importance  of  these  measures. 
(See  p.  695  et  scq.) 

Mechanical  Measures.  Of  all  forms  of  treatment,  nothing 
is  more  useful  in  the  relief  of  symptoms  than  gastric  lavage. 
Even  in  cases  in  which  gastroenterostomy  has  been  practised, 
lavage  becomes  imperatively  indicated  sooner  or  later. 

The  object  of  lavage  in  these  cases  is  threefold :  to  remove 
from  the  stomach  the  accumulated  food-products  that  occur 
in  all  cases  of  pyloric  obstruction ;  to  cleanse  the  mucous 
membrane,  and,  perhaps,  to  increase  its  secretory  power  (al- 
though in  the  majority  of  advanced  cases  we  are  dealing  with 
a  total  achylia,  due  to  permanent  anatomical  defects),  and  to 
get  rid  of  broken-down  cancerous  debris,  and  thus  prevent,  as 
far  as  possible,  the  absorption  of  cancer  toxins.  To  provide  for 
the  first  object  the  best  time  to  lavage  is  late  in  the  after- 
noon, or,  preferably,  three  or  four  hours  after  the  evening 
meal,  which  will  often  insure  the  patient  a  better  night's  rest. 
To  attain  the  other  two  ends,  morning  lavage  of  the  twelve- 
or  fifteen-  hour  fasting  stomach  serves  better.  In  many  cases 
it  becomes  necessary  to  practise  lavage  both  morning  and 
night.  It  is  better  to  use  a  32  or  34  F.  calibrated  stomach- 
tube,  making  use  of  the  Leube-Rosenthal  method  by  which 
lavage  can  be  carried  out  much  more  rapidly  and  thoroughly. 
The  lavaging  solutions  will  depend  upon  the  individual  indi- 
cations in  any  given  case,  and  are  described  in  detail  in  the 
chapter  on  Gastritis.  (See  p.  767.)  To  cleanse  the  stomach 
of  mucus  the  alkaline  solutions  are  best;  to  promote  secre- 
tion a  solution  of  sodium  chlorid  is  probably  most  efficient, 
although  silver  nitrate  or  hydrochloric  acid  solutions  may  be 
used.  Where  there  is  considerable  sloughing  of  a  cancer  mass 
with  a  foul,  putrid  odor  of  decomposing  tissue,  the  writer 
prefers  the  use  of  a  solution  of  potassium  permanganate 
in  a  dilution  strength  of  1 :  15,000,  gradually  increasing  to 
1 :  10,000,  which  is  to  be  promptly  removed,  and  the  stomach 
thoroughly  rinsed  with  plain  water.     Other  useful  solutions 


740  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

are  1  per  cent,  or  2  per  cent,  formalin,  1  per  cent,  salic^'lic 
acid,  or  resorcin  15  grains  to  the  quart  (1  Gm.  to  1000  mils). 

While  the  use  of  these  antiseptic  solutions  may  not  accom- 
plish much  in  themselves,  nevertheless  lavage  uniformly 
results  in  symptomatic  improvement,  and  the  promotion  of 
a  sense  of  well-being.  As  a  direct  result  patients  eat  better, 
sleep  better  and  feel  better,  and  the  lavage  should  be  con- 
tinued until  the  weakness  of  the  patient  and  the  general 
exhaustion  attendant  upon  it  contraindicates  its  further  use. 
At  the  conclusion  of  each  lavage  a  small  amount  of  liquor 
antisepticus  alkalinus,  or  a  solution  of  essence  of  peppermint, 
just  pleasantly  aromatic,  may  be  left  in  the  stomach  on  all 
occasions  save  when  medicinal  agents,  such  as  castor  oil, 
novocaine,  cerium  oxalate,  and  similar  drugs  are  to  be  intro- 
duced through  the  tube. 

In  cancer  affecting  the  cardiac  portion  of  the  stomach  gas- 
tric lavage  cannot  be  practised,  but  in  cases  in  which  the 
cardiac  stenosis  is  not  so  great  as  to  forbid  feeding  by  the 
mouth,  it  is  useful  occasionally  to  wash  out  the  esophagus, 
so  as  to  prevent  the  occurrence  of  a  localized  esophagitis  due 
to  retained  decomposing  foods. 

Dietetic  Measures.  In  cancer  of  the  stomach  there  can  be 
no  stereotyped  diet  which  can  be  made  to  apply  to  all  cases. 
The  diet  for  each  patient  must  be  selected  to  meet  the 
individual  requirements,  and  the  choice  and  character  of  foods 
will  depend  to  a  considerable  extent  upon  the  location  of  the 
cancerous  growth.  Naturally,  cases  in  which  there  is  pyloric 
growth  sufficient  to  cause  obstruction  will  have  to  be  fed  on 
a  liquid  or  a  soft  mushy  diet,  in  as  highly  concentrated  a 
form  as  possible,  and  in  amounts  and  in  frequency  to  be 
determined  by  the  emptying  power  of  the  individual  stomach. 
In  those  cases  in  which  cancer  implicates  the  fundus,  or  the 
lesser  curvature  awa}^  from  the  pylorus,  more  latitude  can  be 
given  in  the  selection  of  a  semisolid  or  a  solid  diet. 

It  is  ver}^  important  that  the  likes  and  dislikes  of  the 
individual  patient  for  food  be  catered  to,  and  that  they  be 
allowed  to  eat  as  freely  of  such  foods  as  they  prefer,  and 
which  are  adapted  to  the  motor  and  secretor}^  power  of  their 
stomach,  without  producing  an  aggravation  of  symptoms. 
Nothing  reacts  more  quickly  upon  the  general  condition  of 


CARCINOMA  OF  THE  STOMACH.  741 

the  patient  than  when  he  is  obliged  to  follow  an  unpalatable, 
monotonous  diet.  With  this  plan  there  soon  follows  loss  of 
appetite  and  suppression  of  whatever  psychic  juice  may  be 
present,  due  to  mental  rebellion. 

Having  settled  upon  the  kinds  of  food  that  appeal  to  the 
individual  patient,  and  which  can  be  eaten  with  symptomatic 
agreement,  the  general  principles  of  the  food  are  that  they 
shall  be  furnished  in  as  bland  a  form,  and  in  as  fine  a  state 
of  subdivisions  as  possible.  Having  placed  the  mouth  and 
teeth  in  as  good  a  state  of  cleanliness  and  repair  as  can  be 
accomplished,  careful  mastication  should  be  insisted  upon. 
In  other  words,  the  stomach  should  be  relieved  of  any 
unnecessary  expenditure  of  digestive  energy,  both  mechanical 
and  chemical,  which  can  be  accomplished  by  other  means 
{e.g.,  proper  preparation  of  food  in  the  kitchen,  thorough 
mastication,  etc.).  Of  foods  that  are  generally  acceptable 
may  be  mentioned  highly  concentrated  soups  and  broths  of 
all  kinds,  boiled  milk,  milk  foods,  cream,  buttermilk,  a  liberal 
use  of  butter  and  olive  oil,  minced  chicken  or  other  fowl, 
creamed  oysters,  soft-boiled  or  lightly  poached  eggs,  and  all 
kinds  of  non-scratchy  vegetables,  which  are  to  be  thoroughly 
cooked,  passed  through  a  sieve,  and  served  in  the  form  of  a 
puree;  zwiebach,  dry  toast,  or  stale  bread  may  be  eaten 
freely,  if  softened  by  dipping  into  soup  or  milk;  meats,  such 
as  beefsteak,  roast  beef,  lamb,  and  veal  may  be  occasionally 
eaten,  if  they  are  first  passed  through  a  meat  grinder.  Should 
there  be  any  marked  pyloric  obstruction,  they  need  not  be 
minced  so  finely,  but  may  be  chewed  thoroughly,  and  the 
meat-juice  swallowed,  but  the  connective  tissue  and  pulp  dis- 
carded. Salads,  if  finely  cut,  may  be  eaten  occasionally.  Sim- 
ple desserts,  such  as  soft  puddings,  ice-cream,  and  the  like, 
may  be  eaten,  the  preference  being  given  to  those  made  with 
milk  or  cream.  Cooked  cereals  are  permissible  and  useful 
when  desired  by  the  patient.  Stewed  fruits  may  be  taken, 
provided  that  they  do  not  increase  gastric  fermentation,  and 
this  applies  also  to  other  articles  of  diet.  Non-aerated  bever- 
ages may  be  used  freely,  and  alcohol  taken  in  medicinal 
amounts.  It  is  well  to  avoid  strong  cofifee,  especially  at  night. 
As  Ochsner  suggests,  it  is  well  to  avoid  uncooked  foods,  par- 
ticularly fruits,  roots,  and  vegetables  which  are  likely  to  be 


742  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

contaminated  by  manure.  Regarding  the  use  of  oils  and  fat, 
while  they  serve  well  to  increase  the  caloric  value  of  the  diet, 
they  leave  the  stomach  slowly,  and  are  prone  to  increase 
butyric  acid  fermentation.  The  quantity  and  quality  of  gas- 
tric secretion  is  a  useful  guide  in  the  selection  of  individual 
food.     (C/.  p.  692.) 

In  some  cases  where  the  pyloric  obstruction  is  advanced  it 
ma}-  be  necessar}-  to  resort  to  duodenal  feeding,  if  the  catheter 
can  be  passed  successfully.  To  this  end  the  use  of  a  duodenal 
tube  without  the  metal  tip,  which  can  be  passed  over  a  silk 
thread,  previously  swallowed,  ser\'es  the  purpose  best,  inas- 
much as  the  duodenal  catheter  can  be  withdrawn  when  not 
in  use,  stands  less  chance  of  food  blockage  while  being  used, 
can  be  more  easily  kept  clean,  and  gives  less  discomfort  to  the 
patient.  The  foods  suitable  for  duodenal  feeding  and  the 
methods  of  their  use  have  been  discussed  in  detail  in  the  dis- 
cussion of  gastric  ulcer.     (C/.  p.  703.) 

Rectal  alimentation  may  have  to  be  used  in  such  patients 
in  whom  sufficient  nourishment  cannot  be  provided  othenvise. 
As  a  means  of  relieving  thirst,  the  nutrient  enema,  preceded 
or  followed  by  a  short  period  of  proctoclysis,  is  useful,  and 
serves  to  combat  acidosis.     (C/.  p.  699.) 

Medicinal  Measures.  Chemical  therapy  is  indicated  for  the 
control  of  certain  symptoms,  but  it  should  be  supplemental  to 
lavage.  It  is  more  important  than  dietetics  in  the  treatment 
of  gastric  carcinoma,  and  drugs  are  useful  for  the  correction 
of  secretorv  defects,  to  promote  better  states  of  nutrition,  and 
to  control  certain  special  symptoms,  notably  pain. 

If  there  is  hyperacidity  or  hypersecretion,  the  use  of  alka- 
lies is  indicated,  and  a  wide  selection  of  these  agencies  is 
available.  Of  most  conspicuous  importance  are  soda  bicar- 
bonate, various  forms  of  magnesia,  particularly  if  there  is  con- 
stipation, and  the  various  alkaline  waters.  (C/.  p.  701.)  In  a 
certain  number  of  cases,  even  though  the  gastric  secretion  is 
not  high,  symptomatic  relief  is  obtainable  from  alkalies.  As 
a  rule,  however,  where  gastric  secretion  is  diminished  or 
absent  the  use  of  the  dilute  hydrochloric  acid  in  a  dosage  of 
20  to  30  drops  (1.25  to  1.9  mils),  well  diluted  with  water  and 
taken  in  small  amounts,  with  or  after  the  meals,  gives  the 
better  result.     Acidol  tablets  or  oxyntin  (Fairchild's)  may  be 


CARCINOMA  OF  THE  STOMACH.  743 

substituted.  A  good  method  of  administering  hydrochloric 
acid  is  in  the  form  of  acidulated  milk.  (See  p.  778.)  The  use 
of  the  artificial  enzymes  is  generally  stated  to  be  valueless. 
With  a  state  of  gastric  anacidity  the  writer  believes  that  an 
effective  administration  of  enzymes  can  be  accomplished  from 
the  use  of  pancreatin  or  pankreon  in  SO-grain  (3  Gm.)  doses, 
given  in  combination  with  an  alkaline  powder,  two  or  three 
hours  after  eating. 

As  a  stimulant  to  the  appetite,  aside  from  lavage,  one 
may  use  various  stomachic  tonics,  such  as  conduranago,  nux 
vomica,  hypophosphites  and  gentian.  The  writer  has  found 
the  following  combination  of  service  in  some  cases : 

IJ  Tincture  nucis  vomici  3iv  (15.0  Gms.). 

Fluidextract  condurango  '5j   (30.0  Gms.). 

Tincture  gentian,  comp.,  q.  s.  ad  5vj   ( 180.0- Gms.) . 
Vel 

Elixir  hypophosphitum  (N.F.) 

q.  s.  ad  5vj   (180.0  Gms.). 
M.    S. :    One  or  two  teaspoonfuls  (3.75  to  7.50  mils)  to 
be  taken   in   a  little  water  thrice   daily  before 
meals. 

To  combat  anemia  one  may  substitute  as  a  vehicle  in  the 
foregoing  prescription  the  elixir  of  gentian  and  iron  phosphate 
(N.F.),  or  the  elixir  of  hypophosphite  and  iron  (N.F.).  Cap- 
sules of  iron,  quinine,  strychnine  and  arsenic  may  be  used  for 
the  same  purpose,  in  the  following  combination : 

IJ  Ferri  carbonatis    gr.  iij    (0.19  Gm.). 

Quinini  sulphatis  ...- gr.  j   (0.06  Gm.). 

Ext.  nucis  vomici  gr,  ^   (0.015  Gm.). 

Acidi  arsenosi gr.  %o  (0.0012)   Gm.). 

M.  et  ft.  caps.  no.  j. 

S. :    Give  such  a  capsule  thrice  daily. 

As  in  so  many  other  gastric  conditions  the  writer  thor- 
oughly believes  in  the  hypodermic  use  of  drugs  intended  to 
stimulate  the  blood-forming  organs,  inasmuch  as  the  dose 
given  and  absorbed  can  be  more  readily  controlled  without 
danger  of  upsetting  the  stomach.  The  contents  of  an  ampoule 
containing  1,  2  or  3  grains  (0.06,  0.13  or  0.19  Gm.)  each  of  the 
citrate  of  iron  and  the  cacodylate  of  soda,  alone  or  in  coinbi- 
nation,  may  be  injected  intramuscularly  in  the  buttocks  once 
a  day  or  every  second  day. 


744  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

For  the  control  of  pain,  when  due  to  pylorospasm  or  to 
hyperperistalsis  secondar}-  to  pyloric  obstruction,  the  use  of 
olive  oil  before  meals,  or  a  2  to  5  per  cent,  solution  of  anes- 
thesin  in  olive  oil  given  before  meals,  or  through  the  stomach- 
tube,  following  lavage,  frequently  proves  eftective,  especially 
when  combined  with  the  use  of  alkalies.  Authorities  differ 
as  to  the  use  of  orthoform,  but  in  the  writer's  experience  it 
has  never  proved  as  efficacious  in  cancer  as  it  has  in  ulcer. 
Sooner  or  later,  however,  one  will  have  to  resort  to  various 
members  of  the  narcotic  group.  It  is  wiser  to  delay  their  use 
as  long  as  possible,  and  to  begin  with  codein,  giving  ^  grain 
(0.16  Gm.)  once  or  twice  a  day  by  mouth,  and  increasing  the 
frequency  as  occasion  demands.  Later  one  must  make  use 
of  morphine,  which  always  should  be  given  hypodermically 
and  in  a  dosage  and  frequency  only  sufficient  to  control  in- 
creased pain.  Opium  may  be  administered  by  bowel,  if  neces- 
sary, in  the  form  of  a  suppository.  Lockwood  speaks  highly 
of  the  use  of  the  following  prescription,  which  he  believes  is 
more  easih-  tolerated  than  morphine : 

IJ,  Pulvis  opii  denarcot gr.  ss   (0.03  Gm.). 

Pulvis  aromatici  gr.  ivss   (0.28  Gm.). 

M.  et  ft.  caps.  no.  j. 

S. :     One  capsule,  two  or  more  times  a  day. 

Another  useful  formula  for  pain  is  the  following,  recom- 
mended by  Bassler: 

B  Cocainse  hydrochloridum    gr.  xj    (0.7  Gm.). 

Tinct.  valerianje  oij    (60.0  Gms.). 

Aquje  chloroformi q.  s.  ad  Siv  (120.0  Gms.). 

M. 

S. :    Take  1  teaspoonful  (3.75  mils)  in  water,  through 
a  tube,  every  four  hours. 

One-half  to  1  grain  (0.03  to  0.06  Gm.)  of  novocaine  may 
be  dissolved  in  1  or  2  ounces  (30  or  60  mils)  of  distilled  water 
and  introduced  through  the  stomach-tube  at  the  conclusion  of 
the  morning  or  evening  lavage.  The  writer  prefers  novocaine 
to  cocaine  on  account  of  its  lower  degree  of  toxicity. 

While  on  general  principles,  it  is  much  wiser  to  avoid  the 
use  of  narcotics  for  the  relief  of  pain,  yet  the  writer  believes 
that  in  gastric  cancer,  as  well  as  in  cancer  of  other  organs, 


CAkCTNOMA    OF    THE    STOMACH.  74S 

we  are  dealing  with  an  incurable  malady,  and  if  pain  is 
obviously  so  severe  as  to  need  opiates,  it  is  thoroughly  justifi- 
able that  they  should  be  not  only  used,  but  pushed,  if  neces- 
sary, to  the  complete  control  of  unnecessary  suffering.  Can- 
cer, as  a  rule,  kills  before  the  drug  habit  can  be  formed,  and 
such  patients  are  at  least  entitled  to  a  painless  death. 

Care  of  the  Bowels.  The  bowels  should  be  kept  well 
opened,  preferably  by  the  use  of  castor  oil,  which  can  be 
readily  given  through  the  stomach-tube  at  the  conclusion  of 
lavage,  or  administered  in  combination  with  malt-extract, 
beer,  whislcy,  wine,  or  the  syrup  of  sarsaparilla.  No  other 
laxative  is  as  good  in  its  effect  upon  gastric  and  intestinal 
fermentation.  Calomel  is  useful  on  account  of  its  antiseptic 
properties,  and  may  be  given  once  or  twice  a  week  in  a  single 
5-grain  (3  Gm.)  dose  at  bedtime.  It  is"  better  to  use  liquid 
petrolatum  as  an  intestinal  lubricant,  in  tablespoonful  (15  mils) 
doses,  once  or  twice  a  day,  reinforced  by  cleansing  enemata, 
and  where  laxatives  have  to  be  continued  for  a  longf  time,  in 
addition  to  those  mentioned  above,  alophen  pills  and  cascara 
sagrada  have  a  distinct  value. 

For  the  control  of  other  special  symptoms  the  reader  is 
referred  to  the  discussion  of  Gastric  Ulcer.     (See  p.  684.) 

The  use  of  the  .^--ray  has  long  been  advocated  as  a  pallia- 
tive, and  even  as  a  curative  measure,  in  the  treatment  of 
inoperable  cancers.  Of  its  use  in  gastric  cancer  the  writer 
knows  nothing  from  personal  observation,  but  he  believes  that 
it  would  prove  far  less  successful  than  in  the  treatment  of 
cancer  involving  the  external  organs  or  surfaces  of  the  body. 
Certainly,  treatment  by  x-raj  should  never  be  urged  as  an 
alternative  to  surgical  exploration,  whether  early  or  late. 

In  comparatively  recent  years  the  use  of  certain  metals, 
such  as  radium,  mesothorium,  selenium,  and  the  like  have 
found  their  way  into  the  literature,  and  cases  have  been 
reported  with  good,  bad  and  indilTerent  results  from  this  sort 
of  therapy.  For  some  years  to  come  the  use  of  radium  for 
this  purpose  will  be  greatly  restricted  on  account  of  its 
scarcity  and  dearness,  and  its  use  can  be  made  accessible  only 
to  the  very  rich.  As  a  substitute  radioactive  waters  have 
come  more  prominently  to  the  fore,  and  when  taken  in  suffi- 
cient quantities  may  prove  useful  in  breaking  down  or  taking 


746  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

care  of  a  superficial  cancer  slough,  as  in  certain  cases  of 
colloid  cancer. 

In  the  seven  or  eight  years  that  have  elapsed  since 
Hodenpyl  brought  forward  the  use  of  a  specific  serum  therapy 
in  the  treatment  of  cancer,  which  ended  with  his  untimely 
death,  not  much  has  been  accomplished  except  to  bring  this 
form  of  treatment  into  considerable  disrepute  among  the 
better  members  of  the  medical  profession,  who  have  lost  faith 
in  the  different  cancer  autolysates,  which  have  recently  been 
urged  on  an  unsuspecting  public.  On  the  other  hand,  the 
medical  profession  is  awaiting  with  some  interest  further 
reports  of  the  success  of  vaccination  with  split-proteids  as 
inaugurated  by  the  two  Vaughans. 

In  a  disease  so  deadly  and  dreaded  as  inoperable  cancer 
we  would  eag'erly  like  to  grasp  every  therapeutic  straw,  on 
the  ground  that  anv  form  of  treatment  may  be  justifiable,  yet 
it  is  well  to  remember  that  man}^  of  these  later  methods  of 
treatment,  even  though  they  promise  well,  are  still  in  their 
experimental  infancy,  and  we  should  be  conservative  in  our 
decision  to  adopt  them  blindly.  Time  alone  will  show  their 
real  utility. 

SARCOMA    OF  THE    STOMACH. 

Sarcoma  of  the  stomach  is  a  malignant  neoplasm  spring- 
ing from  atypical  cell  proliferation  of  connective-tissue  origin, 
and,  therefore,  exists  as  a  tumor  primarily  invading  the  walls 
of  the  stomach,  with  comparatively  infrequent  extension  into 
the  mucous  lining  or  into  the  serous  coat.  Its  course  is 
similar,  in  many  respects,  to  that  of  cancer,  although  its  onset 
may  be  even  more  insidious  and  symptomless.  Its  duration 
is  somewhat  longer,  as  a  rule,  than  that  of  cancer,  but  it 
invariably  terminates  fatally,  and  some  cases  run  an  exceed- 
ingly rapid  course.  Like  sarcomas  elsewhere,  it  metastasizes 
by  way  of  the  blood-vessels,  and  extragastric  metastatic 
growths  may  be  early  and  widespread.  ^Metastatic  sarcoma 
of  the  skin  is  not  infrequent,  and  when  present  is  a  strong 
supportive  evidence  of  the  presumptive  diagnosis.  Unlike 
cancer,  metastatic  invasion  is  much  less  frequent  than  the 
spread  of  the  process  by  direct  continuity. 

Sarcoma    is    a   relatively    rare    malignant    tumor    of    the 


SARCOMA  OF  THE  STOMACH.  747 

stomach.  Since  first  clescril^ed  by  Virchow  there  have  l)een 
approximately  more  than  180  cases  reported  in  the  literature. 
Gossett,'^^  in  1912,  reported  171  cases  that  he  had  collected. 
Smithies/'^i  in  1916,  mentions  4  cases  of  gastric  sarcoma  ob- 
served among  his  921  cases  of  gastric  cancer,  an  incidence 
approximately  of  0.25  per  cent.  Some  writers,  notably  Fen- 
wick,^-  feel  that  the  true  incidence  of  sarcoma  among  gas- 
tric neoplasms  M^ould  be  found  to  be  considerably  higher  if 
accurate  microscopic  diagnoses  were  more  carefully  made  in 
all  gastric  tumors,  and  he  estimates  its  frequency  at  from  5 
to  8  per  cent.  This  view  is  shared  by  Perry  and  Shaw,  who 
found  4  cases  of  gastric  sarcoma  in  a  series  of  50  cases  -of 
gastric  malignancy.  These  figures  are  doubtless  too  high,  and 
probably  Lockwood's,-'^^  estimate  of  1  per  cent,  comes  nearer 
the  true  facts. 

Both  sexes  seem  to  be  equally  susceptible,  although  the 
age  incidence  shows  it  to  occur  in  young  adults  far  more  fre- 
quently than  cancer. 

Our  knowledge  of  the  etiologic  factors  is  even  less  than 
that  of  cancer.  Brooks-^*  reports  a  case  occuring  in  the  scar 
of  an  old  bullet  wound  in  the  stomach-wall,  which  he  ascribes 
directly  as  a  result  of  local  trauma.  It  is  possible  that  in  some 
instances  the  neoplasm  in  question  occurs  in  the  form  of  a 
sarcomatous  degeneration  of  a  benign  tumor,  such  as  a 
myofibroma. 

Pathologically,  sarcoma  may  occur  as  a  localized  tumor 
of,  or  as  a  dififused  infiltration  through,  the  wall  of  the 
stomach,  and  its  size  may  vary  from  a  small  nodule  to  a 
tumor  the  size  of  a  large  grapefruit.  Salomon"-"*  reports  1 
case  in  which  the  tumor  weighed  fourteen  pounds.  It  shows 
about  equal  tendency  to  extend  its  growth  toward  the  mucous 
membrane  and  the  serous  coat,  but  microscopic  examination 
of  the  glandularis  has  generally  shown  it  to  remain  intact. 

Histologically,  sarcoma  of  the  stomach  may  be  classified 
in  the  same  grouping  used  for  extragastric  sarcoma,  although 
the  round-cell  and  spindle-cell  varieties  are  notably  frequent 
when  the  stomach  is  the  seat  of  this  new  growth. 

The  location  of  the  tumor  is  more  widespread  than  in 
cancer,  although  most  frequently  it  afifects  either  the  pylorus 
or    the    greater    curvature,    but,    even    so,    it    rarely    shows 


748  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

the  degree  of  pyloric  obstruction  so  common  in  gastric 
carcinoma. 

Gastric  sarcoma  may  occur  either  as  a  primary  or  a  sec- 
ondary growth,  although  the  latter  form  is  exceedingly  rare, 
and  is  likely  to  be  of  the  melanotic  variety.  Of  the  different 
t3'pes,  the  round-cell  sarcoma  is  more  prone  to  undergo 
metastases,  chiefly  in  the  l3^mph-glands,  and  to  a  less  extent 
in  the  liver  and  kidneys. 

None  of  the  symptoms  are  characteristic,  and  an  accurate 
diagnosis  cannot  be  made  from  the  anamnesis.  Cachexia  and 
emaciation  occur  early.  There  may  be  few  distinctly  gas- 
tric symptoms.  Even  when  the  pylorus  is  involved,  vomit- 
ing occurs  much  less  frequently  than  in  cancer,  and  is  rarely 
of  the  retention  type.  Vomiting  of  blood,  however,  is  rather 
common,  and  is  usually  more  copious  than  is  the  rule  in 
cancer. 

A  low  grade  of  continuous  fever  has  been  noted  in  some 
instances.  Anemia  of  the  secondary  type  is  usually  marked, 
and  is  a  rather  suggestive  finding,  although  it  does  not  differ 
from  that  seen  in  severe  chlorosis.  The  appetite  is  capricious, 
and  early  anorexia  is  not  uncommon,  although  there  do  not 
appear  to  be  the  food  aversions,  which  are  not  uncommon  in 
cancer  cases. 

Pain  is  a  rather  constant  symptom,  and  may  vary  from  a 
sense  of  epigastric  weight  and  pressure  to  true  colicky,  cramp- 
like pains,  similar  to  those  occurring  in  biliary  colic ;  pain  is 
a  frequent  complaint  in  sarcomas  that  progress  in  the  direc- 
tion of  the  mucous  membrane. 

Chemical  analyses  of  the  gastric  juice,  as  a  rule,  yield  little 
information.  Secretory  errors  are  less  common  than  in  cancer, 
although  subacidities  appear  more  frequent,  notwithstanding 
the  preservation  of  an  apparently  normal  glandularis.  Oppler- 
Boas  bacilli  and  the  presence  of  lactic  acid  have  been  noted. 

The  physical  signs  are  typical  only  in  the  demonstration 
of  an  epigastric  tumor  which,  by  the  tuning  fork  and  ausculta- 
tory percussion,  can  usually  be  shown  to  be  limited  to  the 
stomach.  As  a  rule, .the  tumor  mass  is  movable,  and  does  not 
show  the  degree  of  fixation  so  common  in  cancer.  Physical 
examination  may  give  evidence  of  pyloric  obstruction  with 
secondary  dilatation  of  the  stomach.     The  spleen  is  occasion- 


GASTRITIS.  749 

ally  enlarged,  and  in  lymphosarcoma  Kundrat  has  noted  that 
the  lymphatic  glands  and  commonly  the  lymphoid  tissue  of 
the  tonsils  are  likely  to  be  enlarged.  The  prognosis  of  gastric 
sarcoma  is  invariably  bad,  inasmuch  as  but  few  cases  are 
diagnosed  early  enough  to  permit  of  surgical  interference. 

The  treatment  of  sarcoma  of  the  stomach  is  essentially 
surgical.  In  a  suspected  case  the  only  hope  lies  in  an  early 
exploratory  operation,  with  the  possibility  of  finding  the 
tumor  sufficiently  localized  to  justify  a  radical  excision.  In 
the  presence  of  metastases  resection  is  inadvisable  on  account 
of  disseminating  the  pathologic  process  by  way  of  the  newly 
opened  blood-vessels. 

The  non-surgical  treatment  of  sarcoma  is  practically  the 
same  as  that  described  for  cancer,  except  that  Coley's-^*^  mixed 
vaccine  should  be  tried  in  all  cases.  If  improvement  does  not 
follow  within  a  few  weeks,  but  little  good  can  be  expected 
from  its  further  administration. 


GASTRITIS. 

Gastritis  is  much  too  commonly  diagnosed  without  suffi- 
cient pathologic  evidence,  and  this  is  necessarily  so  in  any 
disease  in  which  it  is  difficult  to  furnish  the  pathologic  proof. 
In  all  the  field  of  gastroenterology  no  diagnosis  is  more  fre- 
quently made  than  that  of  gastritis,  and  it  is  probably  safe  to 
say  that  in  more  than  50  per  cent,  of  cases  the  diag^nosis  is 
wrong.  Many  cases  of  chronic  appendicitis,  and  of  chronic 
gall-bladder  disease,  giving  rise  to  reflex  gastric  symptoms, 
are  allowed  to  masquerade  under  the  diagnosis  of  gastritis. 
It  is  very  essential  that  the  pathologic  proof  be  furnished 
before  such  a  diagnosis  can  be  emphatically  affirmed.  There 
are  two  particular  elements  in  the  proof  that  should  be  dem- 
onstrated :  first,  an  increase  in  intimately  mixed,  endogenous 
mucus  to  be  seen  in  the  gastric  contents  or  vomitus;  and, 
second,  the  demonstration  of  inflammatory  elements  in  the 
gastric  sediment,  such  as  an  increase  of  leucocytes,  red 
blood-cells,  and  exfoliating  epithelial  cells  of  gastric  origin. 
In  the  more  fortunate  cases  one  may  recover  bits  of  mucous 
membrane,  sometimes  including  its  whole  depth  from  the 
periphery  to  the  muscularis  mucosa,  and  a  study  of  this  will 


750  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

show  pathologic  alterations  from  which  the  diagnosis  can  be 
definitely  made.  As  a  general  rule,  pathologic  defects  which 
invade  only  the  glandular  portion  of  the  mucosa  indicate  an 
acute  process  of  the  catarrhal  t3'pe.  Invasion  of  the  deeper 
layers,  with  pathologic  elements,  means  that  the  condition  has 
become  chronic ;  hence,  with  certain  exceptions,  we  can  divide 
our  inflammatory  diseases  of  the  stomach  into  acute  and 
chronic  types,  and  both  of  these  should  be  further  classified 
into  primary  and  secondar}-  forms.  There  are  four  types  of 
acute  gastritis :  acute  simple  gastritis,  acute  toxic  gastritis, 
acute  infectious  gastritis,  and  acute  phlegmonous  gastritis. 
The  dififerential  diagnosis  of  these  four  types  can  best  be  built 
upon  a  platform  of  etiologic  factors,  rather  than  pathologic 
facts. 

Acute  Simple  Gastritis  (Acute  Catarrhal  Gastritis). 
The  primary  form,  while  less  common,  may  result  from 
mechanical  irritants,  such  as  coarse  food,  improperly  cooked, 
and  when  eaten  too  rapidly  and  in  too  large  amounts ;  from 
chemical  irritants,  such  as  the  ptomaines  in  decomposing 
food,  the  excessive  use  of  alcohol  (an  alcoholic  debauch),  the 
overindulgence  in  irritating  condiments,  or  a  mixture  of  rich 
foods  that  are  not  suitable  to  the  individual's  digestive 
apparatus.  Among  other  chemical  irritants  which  tend  to 
produce  a  gastritis  are  the  accidental  ingestion  of  caustic 
alkalies  or  acids,  or  the  long-continued  medicinal  use,  in  cer- 
tain cases,  of  drugs  such  as  arsenic,  iron  and  phosphorus  (the 
gastrite  medicamenteiise  of  the  French  writers).  Thermal  irri- 
tants, such  as  overindulgence  in  too  hot  or  too  cold  foods  or 
drinks,  predispose  to  acute  gastritis.  Particularly  if  alcoholic, 
the  iced  drinks  so  common  in  America,  are  contributing  fac- 
tors of  considerable  importance.  Secondary  acute  gastritis  is 
a  common  complication  of  the  acute  infectious  diseases,  such 
as  typhoid  fever,  pneumonia  and  influenza,  and  of  such  con- 
stitutional diseases  as  nephritis  and  gout. 

Acute  gastritis  is  common  to  all  ages,  and  in  the  A^ery 
young  may  be  an  extremely  serious  condition,  and  in  the  xevj 
old  may  result  fatally.  The  prognosis,  in  simple  acute  gas- 
tritis, is  uniformly  good,  except  in  those  cases  altecting  the 
two  age  extremes.  The  symptoms  usually  promptly  subside 
when  the  ofifendinsr  cause  is  removed. 


GASTRITIS.  751 

The  direct  indications  of  treatment  are  the  adoption  of 
measures  to  combat  an  inflammation  of  the  gastrointestinal 
tract,  and,  secondarily,  to  overcome  such  depressive  symptoms 
as  may  occur  as  the  result  of  a  toxemia.  At  the  earliest  pos- 
sible opportunity  the  stomach  should  be  emptied  of  its  irri- 
tating, often  stagnating,. contents,  preferably  by  lavage,  using 
2  to  3  quarts  (2  to  3  1.)  of  normal  salt  solution,  or  a  deci- 
normal  solution  of  soda  bicarbonate,  which  should  be  fol- 
lowed by  some  bland  alkaline  solution,  such  as  the  liquor 
antisepticus  alkalinus.  If  the  stomach-tube  is  not  available, 
emesis  should  be  secured  by  the  administration  of  several 
glasses  of  warm  water  (to  which  may  be  added  a  teaspoon- 
ful  of  English  mustard  to  the  liter),  or  by  inducing  vomit- 
ing by  tickling  the  pharynx  with  the  finger.  It  is  not  wise 
to  use  irritating  emetics.  A  single  hypodermic  injection  of 
apomorphin,  %o  grain  (0.006  Gm.),  may  be  used  in  cases 
in  which  emesis  cannot  otherwise  be  secured,  provided  that 
there  are  no  symptoms  of  collapse.  In  such  cases  apomor- 
phin should  be  given  cautiously  on  account  of  its  depressing 
action.  Both  Boas  and  Ewald  recommend  the  use  of  ipecac 
and  tartar  emetic,  in  the  following  combination: 

IJ  Pulvic  ipecacuanhse   gr.  xxij   (1.5  Gm.). 

Antimonii  et  potassii  tartaris  gr.  %  (0.05  Gm.) 
Ft.  chart  no  j. 

S. :  Take  entire  contents  of  powder  either  at  a 
single  dose,  or  in  quarter  amounts  at  intervals 
of  ten  minutes. 

In  children  it  is  better  to  use  the  syrup  of  ipecac  in  a 
single  dose  of  1  teaspoonful  (3.75  mils),  or,  in  younger  chil- 
dren, 15  or  20  minims  (0.9  or  1.5  mils)  every  ten  minutes 
until  emesis  has  been  secured.  In  all  cases  promptness  in 
emptying  the  stomach  is  most  desirable,  inasmuch  as  it  serves 
to  get  rid  of  the  offending  cause,  and  further  protects  the 
intestines  against  receiving  the  irritating  material,  either  in 
whole  or  in  part.  The  second  important  measure  is  promptly 
to  empty  the  intestinal  tract.  Calomel  is  the  drug  par  excel- 
lence for  this  purpose,  on  account  of  its  antiseptic  and  disin- 
fecting properties,  in  addition  to  its  purgative  effect.  It  is 
probably  best  to  use  two  large  doses,  5  or  6  grains  (0.32  or 
0.40  Gm.)  each,  as  suggested  by  Ewald,  taken  one  hour 
apart,  than  to  use  smaller  amounts  in  divided  doses.     Before 


752  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

waiting  for  the  calomel  to  take  effect  the  lower  bowel  should 
be  emptied  by  a  high  colonic  irrigation.    The  saline  laxatives 
and  castor  oil  had  best  be  avoided.     If  the  stomach  is  not 
retentive  to  the  use   of  calomel,  its   second   dose   should  be 
deferred  until  the  second  day  after  the  attack.     Should  other 
than  a  physiologic  diarrhea  ensue,  one  of  the  best  measures 
is  to  use  a  bolus  of  white  clay  or  Fuller's  earth  in  a  dosage 
of  >4  to  1  ounce  (15  to  30  Gms.)  suspended  in  a  little  milk  or 
water,  and  this  may  be  repeated  in  three  or  four  hours,  if 
necessary.     After  emptying  the  stomach  no  foods  should  be 
given  by  mouth  for  several  days,  in  order  to  allow  the  inflam- 
mation of  the  gastric  mucous  membrane  to  subside,  and  also 
to  suppress  the  secretion  of  gastric  juices.     Supportive  rectal 
enemata  may  be  used   (see  p.  699),  and  thirst  may  be  con- 
trolled by  sucking  bits  of  cracked  ice,  and  by  the  use  of  2  or 
3  liters  (quarts)  of  normal  salt  solution  or  decinormal  soda 
bicarbonate  solution  daily  by  proctoclysis,  using  the  Murphy 
method,  or  any  of  its  modifications.     The  mouth  should  be 
kept  scrupulously  clean  by  appropriate  measures. 

After  two  or  three  days  of  oral  food  rest,  liquid  diet  may 
be  instituted  in  the  form  of  albumin-water,  peptonized  milk, 
strained  oatmeal,  or  barley-gruel,  and  later  thin  broths,  not 
made  from  meat-stock  or  extract.  After  from  one  to  three 
days  of  liquid  diet,  depending  upon  the  severity  of  the  case, 
soft  foods  may  be  taken  in  the  form  of  soft  eggs,  boiled  or 
poached,  oysters,  oyster-broth,  toast,  bread  and  butter,  cus- 
tards^ junkets,  jellies,  cereals,  etc.,  and  in  a  day  or  two  more 
soft  pureed  vegetables  may  be  added,  and  the  usual  diet  may 
be  resumed  within  from  seven  to  ten  days. 

If  vomiting  should  continue  during  the  period  of  food- 
abstention  the  mechanical  sedatives,  such  as  bismuth  subcar- 
bonate  or  subnitrate  and  cerium  oxalate  may  be  used  in  the 
following  combination : 

IJ  Cerii  oxalatis    gr.  xxv  (1.6  Gms.) . 

Sodii  bicarbonatis, 

Bismuth.!  subcarbonatis   ...aa  Siiss  (10  Gms.), 
Div.  in  chartulas  no.  x. 

S. :     One  powder  to  be  taken  in  a  little  water  every 
hour  until  relieved. 


GASTRITIS.  753 

For  the  relief  of  nausea  and  milder  forms  of  vomiting  the 
sucking-  of  cracked  ice,  to  which  has  been  added  1  or  2  tea- 
spoonfuls  of  brandy,  or  crenic  de  menthc^  will  often  prove 
effective.  If  these  measures  do  not  suffice,  the  stomach  had 
best  be  irrigated  with  a  weak  solution  of  soda  bicarbonate, 
1  or  2  drams  to  the  quart  (3.75  or  7.5  mils),  and  preferably 
by  the  small-tube-syringe  method.  (See  p.  720.)  For  the 
control  of  pain  it  is  rarely  necessary,  and  much  better  not  to 
use  morphin.  Symptomatic  control  can  be  secured,  as  a  rule, 
by  the  use  of  hot  or  cold  abdominal  applications  in  the  form 
of  Priesnitz  bandages,  electric  pads,  or  a  mustard  plaster,  to 
be  worn  until  the  skin  is  thoroughly  reddened,  and  then  fol- 
lowed immediately  by  an  ice-bag.  If  this  does  not  suffice, 
codein  sulphate  in  %-  or  %-  grain  (0.01  or  0.008  Gm.)  doses 
may  be  given  every  third  or  fourth  hour,  or  an  opium  supposi- 
tory may  be  used,  and  repeated  if  necessary.  If  there  are 
symptoms  of  prostration  or  collapse,  the  usual  methods  should 
be  adopted,  among  which  may  be  mentioned  elevation  of  the 
foot  of  the  bed,  hot-water  bottles  to  the  feet,  liberal  use  of 
blankets,  proctoclysis,  and  the  hypodermic  use  of  strychnin 
or  camphorated  oil. 

As  a  rule,  fever  is  never  very  high,  and  it  is  well  to  avoid 
the  use  of  antipyretics,  on  account  of  their  depressing  action. 
An  ice-cap  may,  however,  be  worn.  Following  the  attack  it 
is  wise  to  prescribe  a  tonic  composed  of  strychnin  or  nux 
vomica  and  hydrochloric  acid,  in  some  stomachic  vehicle,  such 
as  gentian.    The  following  prescription  may  be  recommended  : 

B  Tinct.  nucis  vomicae, 

Ac.  hydrochloric!  dil aa  fSij  (7.5  mils). 

Tinct.  gentianje  comp. .  .q.  s.  ad  fjiij   (90  mils). 
M.    S. :    One  teaspoonful  (3.75  mils)  in  a  wineglass- 
ful  of  water  before  meals. 

Acute  catarrhal  gastritis,  secondary  to  the  constitutional 
diseases,  will  rarely  need  other  treatment  than  careful  dieting. 

Toxic  Gastritis.  The  etiologic  factor  consists  of  the  swal- 
lowing, by  mistake  or  with  suicidal  intent,  of  acids,  alkalies, 
metallic  salts,  and  concentrated  oils.  Among  these  may  be 
mentioned  carbolic  acid,  oxalic  acid,  hydrocyanic  acid,  and 
the  mineral  acids,  nitric,  hydrochloric  and  sulphuric ;  caustic 
alkalies,  such  as  lye  and  ammonia;  metallic   salts,   such   as 

48 


754  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

mercur}-,  copper,  silver,  arsenic  and  phosphorus;  raw  alcohol, 
and  various  oils,  like  turpentine  or  copaiba.  The  pathologic 
lesion  varies  from  simple  hyperemia  to  ulceration,  suppura- 
tion, with  or  without  gangrene,  and  perforation.  The  charac- 
ter and  the  extent  of  the  damage  inflicted  depends  upon  the 
amount  of  the  poison  taken,  its  character  (corrosive  or  other- 
wise), its  concentration,  its  length  of  stay  in  the  stomach,  and, 
to  a  great  extent,  upon  the  condition  of  the  stomach,  whether 
empty,  partly  empty,  or  full,  and  to  a  less  extent  upon  the 
character  of  the  food  contained  therein.  Perforation  is  rare. 
Corrosive  ulcers,  discrete  or  confluent,  are  common.  ^lacera- 
tion of  the  mucous  membrane  more  commonly  occurs  after 
the  use  of  caustic  alkalies.  A  fatty  degeneration  of  the  gland- 
ulature  is  most  extreme  after  the  ingestion  of  arsenic  and 
phosphorus. 

The  greatest  amount  of  damage  takes  place  at  the  points 
at  which  the  poisons  maintain  the  longest  stay — the  mouth 
and  pharynx,  the  first  and  the  terminal  portions  of  the 
esophagus,  the  cardia,  and  the  pylorus.  As  ulcers  heal,  cica- 
tricial contracture  ma}^  lead  to  stenoses  and  deformities. 
Esophageal,  cardiac  and  pyloric  obstruction  are  common 
sequels.  The  immediate  prognosis  naturall}-  will  depend  upon 
the  immediate  damage  inflicted  locally,  together  with  the 
toxic  insult  offered  to  distant  organs,  especialh^  the  kidneys 
and  liver.  If  death  does  not  occur,  the  prognosis  will  depend 
upon  the  character  of  the  sequels. 

A^omiting  should  be  immediately  induced  by  forcing  the 
patient  to  drink  several  glassfuls  of  warm  water,  to  which 
should  be  added  the  appropriate  antidote.  This  is  the  first 
emergency  measure.  As  soon  as  a  stomach-tube  can  be  ob- 
tained, the  stomach  should  be  washed  out  with  warm  water, 
medicated  with  the  proper  antidote.  Lavage  should  be  done 
early,  to  minimize  the  danger  of  perforation  from  too  long 
continued  maceration  of  the  gastric  membrane  and  wall. 
One  should  always  risk  the  apparent  danger  of  using  the 
stomach-tube.  Cases  which  will  perforate  will  die.  whether 
lavaged  or  not.  IMasterh-  decision  is  here  worth  infinitely 
more  than  watchful  waiting.  Apomorphin  should  not  be 
used,  as  it  simpl}^  adds  to  the  existing  depression.  In  an 
emergency  case  of  poisoning  it  is  often  difficult  to  remember 


GASTRITIS.  755 

the  most  appropriate  antidote.  In  general,  one  may  hnd 
ready  to  hand  something  that  will  prove  effective  if  one  bears 
in  mind  the  general  principles  of  chemical  neutralization. 
For  the  mineral  acids,  nitric,  hydrochloric  and  sulphuric,  neu- 
tralize the  acid  w^ith  chalk,  magnesia,  washing  soda,  soapsuds, 
silver  polish,  whiting,  or  even  plaster  from  the  wall.  These 
may  be  added  to  the  lavage  water,  following  which  there 
should  be  introduced  through  the  tube  some  demulcent,  such 
as  bland  oils,  olive  or  cotton-seed  oil,  milk,  eggs,  or  mucilage 
of  acacia.  Alkaline  carbonates  are  contraindicated,  since  they 
liberate  carbon-dioxide  gas,  thereby  distending  the  stomach 
and  increasing  the  danger  of  perforation.  Oxalic  acid  must 
be  combated  by  only  those  alkalies  which  will  form  the  in- 
soluble and  non-toxic  calcium  oxalate.  Hence,  one  must 
select  lime-water,  chalk  or  wall-plaster.  With  both  carbolic 
and  phosphoric  acids  one  should  never  use  oil,  because  it 
increases  the  tendency  of  absorption  of  these  two  substances. 
For  the  neutralization  of  the  alkalies,  ammonia,  caustic 
potash,  caustic  soda,  or  lye,  one  should  use  dilute  vinegar, 
lemon-juice  or  orange-juice,  and  follow  this  with  bland  oils, 
milk,  butter  or  lard. 

If  the  patient  does  not  die  from  the  immediate  toxic  effects 
of  the  poison,  the  symptoms  of  pain,  collapse,  shock,  suppres- 
sion of  urine,  and  other  constitutional  symptoms  should  be 
treated  according  to  generally  accepted  principles.  -All  foods 
should  be  withheld  by  mouth  for  a  week  or  ten  days,  during 
which  time  rectal  feedings  should  be  carried  out,  together 
with  the  proper  supportive  measures.  When  oral  feeding  is 
resumed,  it  should  follow  the  plan  outlined  for  acute  catarrhal 
gastritis,  unless  complicated  by  ulcer,  when  the  course  of 
treatment  should  differ  in  nowise  from  that  of  ulcer,  as  dis- 
cussed on  page  703.  The  sequels,  esophageal,  cardiac  and 
pyloric  obstruction  should  be  treated  according  to  the  plans 
outlined  in  detail  elsewhere.     (See  p   801  et  seq.) 

Acute  Infectious  Gastritis.  Infectious  g-astritis  is  the  name 
given  to  an  acute  inflammation  of  the  stomach,  in  which  the 
etiologic  factor,  or  infecting  agent,  is  a  bacterium  other  than 
the  true  pyogenic  group  of  staphylococcus  and  streptococcus. 
This  term  is  likewise  applied  to  those  inflammations  of  the 
gastric  mucous  membrane  resulting  from  the  presence  within 


756  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

the  st  mach  of  vegetable  and  animal  parasites.  Where  the 
infection  is  due  to  the  Klebs-Loffler  bacillus  of  diphtheria,  it 
has  been  designated  membranous  gastritis  (croupous  or 
diphtheritic  gastritis).  It  is  of  rare  occurrence.  Other  in- 
fecting bacteria  alleged  to  be  potential  factors  of  infectious 
gastritis  are  the  typhoid,  typhus  and  anthrax  bacilli,  and  the 
pneumococcus  and  streptococcus,  common  to  puerperal  sep- 
sis. Yeast,  fungi,  favus,  maggots,  roundworms  and  tape- 
worms have  also  been  reported  as  etiologic  factors.  "The 
pathologic  lesion  is  very  similar  to  that  of  a  diphtheritic  in- 
flammation of  other  mucous  membranes.  The  prognosis  is 
grave,  because  the  disease  is  usually  secondary  to  a  severe 
systemic  infection,  whose  original  focus  is  extra-gastric. 
Hence,  the  prognosis  is  that  of  the  primary  infection  com- 
plicated by  a  severe  gastritis.  The  symptoms  are  those  of 
simple  catarrhal  gastritis,  with  the  higher  range  of  fever 
common  to  the  primary  disease.  The  treatment  is  partly 
expectant  and  partly  specific.  The  management  of  the  gas- 
tritis is  essentially  the  same  as  that  of  acute  catarrhal  gas- 
tritis, with  the  addition  to  the  lavaging  fluid  of  germicidal 
antiseptics.  (See  p.  719.)  In  the  future  vaccines  may  have 
a  more  prominent  therapeutic  role  than  they  have  played  in 
the  past.  Stock  vaccines  are  in  order,  after  proper  identifica- 
tion of  the  infecting  organism  has  been  made,  but  should  be 
discarded  in  favor  of  the  autogenous  as  soon  as  the  latter  can 
be  prepared.  As  a  rule,  this  should  not  require  longer  than 
thirty-six  to  forty-eight  hours  after,  the  specific  bacterium  has 
been  isolated.  Hence,  not  more  than  one  or  two  injections  of 
a  stock  vaccine  will  be  required. 

In  bacteremic  cases  it  is  worth  while  trying  the  effect  of 
direct  transfusion  of  blood  obtained  from  an  individual  who 
has  been  rapidly  immunized  by  injections,  in  high  dosage,  of 
a  vaccine  made  from  the  specific  organism  infecting  the 
patient.  The  writer  has  seen  one  remarkable  recovery  from 
this  method  of  procedure  in  a  practically  moribund  case.  The 
same  care  should  be  taken  in  the  selection  of  the  proper  donor 
as  applies  to  transfusions  in  general.  The  simplest  method  is 
the  transference  of  the  whole  blood  by  the  Lindeman  method 
or  by  the  Kimpton-Brown  tubes.  If  transfusion  cannot.be 
carried  out,  the  subcutaneous  or  intramuscular  injection  of  the 


GASTRITIS.  757 

immunized  serum  is  the  measure  next  of  choice.  The  course 
and  progress  of  the  treatment  should  be  governed  by  daily 
blood-cultures  with  colony  counts.  Among  other  measures 
calomel  in  small  repeated  doses  is  useful. 

Acute  Phlegmonous  Gastritis  (Acute  Suppurative  Gastritis, 
Gastric  Abscess).  This, disease  may  occur  as  a  primary  lesion 
or  secondary  to  acute  bacterial  infections,  especially  in  the 
presence  of  a  streptococcic  bacteremia.  As  a  primary  disease 
it  is  extremely  rare.  Only  slig'htly  over  a  hundred  cases  have 
1)een  reported  since  Borel  first  described  it  160  years  ago.  The 
usual  infecting  agent  in  both  the  primary  and  the  secondary 
form  is  the  Streptococcus  hrevis,  sometimes  in  association 
with  bacilli  of  the  colon  gToup.  A  case  has  been  reported 
in  which  the  pneumococcus  was  regarded  as  the  infecting 
organism. 

All  authors  agree  that  the  cause  of  the  disease  is  invariably 
microbic.  The  writer  has  recently  seen  a  case  developing  sud- 
denly on  the  fourteenth  day  after  a  gastroenterostomy  for  an 
obstructive  duodenal  ulcer,  and  which  terminated  fatally  on 
the  fourth  day  after  the  onset  of  acute  symptoms.  In  this 
case  it  may  be  worth  while  to  include  the  principal  facts  in 
relation  with  this  form  of  gastric  disease. 

At  autopsy  the  site  of  the  gastroenterostomy  was  opera- 
tively  perfect,  surgically  clean,  and  showed  no  evidence  of 
stitch  abscesses  or  sloughing  of  tissues  ar'ound  the  stitches. 
The  entire  stomach  wall  was  very  greatly  thickened,  espe- 
cially so  on  the  anterior  wall  from  a  point  about  the  mid- 
fundic  region  to  just  above  the  pylorus.  The  serosal  surface 
was  shiny,  had  a  waxy  appearance,  and  was  of  a  light  grayish- 
pink  color.  The  mucosa  was  smooth,  shiny  and  edematous- 
looking;  the  rugge  were  obliterated  and  the  mucosal  surface 
was  of  a  deeper  reddish  pink,  with  a  few  minute  points  of  a 
deeper  red,  suggesting  petechise.  The  anterior  wall,  at  the 
point  of  greatest  thickness,  which  was  midway  between  the 
greater  and  lesser  curvature,  about  3  inches  (7.62  cm.)  above 
the  pylorus  and  at  a  distance  of  at  least  V/y  inches  (3.81  cm.) 
above  the  level  of  the  gastroenterostomy,  was  the  seat  of  an 
intramural  abscess.  On  cross-section  the  mucous  membrane 
and  the  muscular  coat  with  its  attached  serosa  were  greatly 
thickened,    and    the   interstitial    layers   between    contained    a 


758  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

necrotic  slough  6  mm.  (J4  in.)  in  diameter,  and  extending 
for  a  distance  of  8  cm.  (3.149  in.).  The  anterior  wall,  over 
this  area,  varied  in  thickness  from  1  to  1^  cm.  (}i  to  ^ 
in.).  On  exerting  pressure  the  softer  points  in  this  necrotic 
layer  could  be  partly  pressed  out,  and  appeared  like  drops  of 
very  thick  pus.  Cultures  made  from  the  serosal  surface 
recovered  a  Gram-negative  coccus,  and  culturally  not  strep- 
tococcus, which  was  pathogenic  to  a  guinea-pig  twenty  hours 
after  inoculation.  The  same  organism  was  recovered  from 
the  peritoneal  cavity  and  the  heart's  blood  of  the  guinea-pig. 
Cultures  made  from  the  mucosa  recovered  a  second  organism, 
a  Gram-positive  spore-bearing  bacillus,  which  was  not  patho- 
genic to  guinea-pigs.  In  serial  sections,  made  from  both  the 
anterior  and  posterior  walls,  the  bacteria  could  be  demon- 
strated, and  there  was  a  marked  occurrence  of  stratified 
thrombotic  formations  in  widely  dilated  vessels.  Otherwise 
the  pathologic  features  were  the  complete  cellular  necrosis 
with  the  presence  of  polynuclear  leucocytes,  serum  and  fibrin, 
occurring  between  the  muscularis  mucosae  and  the  muscular 
coat.  The  glandular  portion  of  the  mucous  membrane  was 
strikingly  well  preserved,  and  the  muscular  coats  were  the 
seat  of  an  early  fatty  degeneration.  This  patient  was  in  good 
health,  save  for  his  ulcer  symptoms,  was  a  perfect  surgical 
risk,  and  showed  no  evidence  of  oral  sepsis  or  other  bacterial 
foci  of  infection. 

The  pathology  of  this  condition  is  very  much  as  described 
in  the  foregoing  paragraphs.  The  condition  may  occur,  not 
only  in  the  diffuse  form  described  above,  but  in  small,  cir- 
cumscribed, single  or  multiple  abscesses.  The  symptoms  are 
ushered  in  abruptly,  usually  with  a  chill,  followed  by  a  sud- 
den rise  in  temperature  to  a  rather  high  level,  with  acute 
upper  abdominal  pain,  usually  dry  retching,  and  sometimes 
vomiting.  Cases  have  been  reported  in  which  the  vomitus 
contained  pus  from  which  the  infecting  organism  has  been 
recovered.  Such  diagnoses  made  during  life  are  compara- 
tively rare.  There  is  usually  a  high  leucocytosis.  The  phy- 
sical finding's  are  those  of  any  acute  surgical  inflammatory 
disease  affecting  the  peritoneum,  with  board-like  rigidity 
of  the  upper  recti  muscles,  and  exquisite  tenderness.  In  a 
time  varying  from  one  to  several  days,  the  patient  goes  into 


GASTF^ITIS.  759 

sudden  collapse  with  all  the  evidences  of  shock.  This  may 
be  due  to  perforation,  and  is  usually  the  beginning  of  the  end, 
as  the  patient  passes  rapidly  into  a  state  of  coma,  soon  fol- 
lowed by  death.  In  the  diffuse  cases  the  lethal  termination  is 
usually  prompt.  In  the  circumscribed  form  the  patient  may 
live  for  several  weeks.  In  the  latter  type,  when  diagnosed, 
prompt  surgical  interference  offers  the  only  hope  of  recovery. 
The  mortality  of  unoperated  cases  is  extremely  high,  some- 
thing, over  98  per  cent,  in  the  cases  reported. 

Aside  from  prompt  surgical  intervention,  the  treatment  is 
purely  symptomatic  and  expectant.  The  stomach  may  be 
lavaged  with  a  solution  of  bichlorid  of  mercury  in  a  strength 
of  1 :  10,000,  or  a  solution  of  boric  acid,  using  1  ounce  of  the 
powder  to  a  quart  of  water  (30  Gms.  to  the  liter).  Probably 
these  two  are  as  good  as  any,  although  potassium  perman- 
ganate may  be  tried  in  a  dilution  strength  of  1 :  10,000.  The 
supportive  measures  for  collapse  are  the  usual  ones,  procto- 
clysis, hypodermoclysis,  heat,  and  the  use  of  cardiac  stimu- 
lants, such  as  strychnin,  caft'ein  and  camphor. 

Chronic  Gastritis  (Catarrh  of  the  Stomach).  This  disease 
may  occur  in  either  a  primary  or  secondary  form,  according  to 
the  etiologic  factors  involved.  In  the  primary  form  the  patho- 
logic lesions  of  the  gastric  mucous  membrane  may  be  caused 
from  the  ingestion  of  substances  that  are  irritating  to  the 
mucous  membrane.  These  substances  may  be  of  either  a 
mechanical  character,  such  as  the  coarser,  scratchy  forms  of 
food,  improperly  cooked,  and  usually  eaten  too  hastily  without 
proper  mastication,  and  in  too  large  amounts. 

Thermal  irritants,  such  as  foods  that  are  too  hot  or  too 
cold,  or  foods  that  are  too  highly  seasoned  may  produce  a 
chronic  inflammatory  state  of  the  stomach,  if  their  use  is  too 
long  persisted  in. 

Among  chemical  agents  the  long-continued  use  of  alcohol 
stands  first  in  importance  and  incidence,  and  forms  a  distinct 
type  of  chronic  gastritis  which  can  be  differentiated  from  the 
others.  The  cafe,  grill,  or  bar-room  habitue  is  particularly 
prone  to  this  condition,  especially  when  indulging  in  late  sup- 
pers or  dinners  selected  from  the  usual  cafe  menu.  Among 
other  chemical  irritants  the  medicinal  use  of  iron  and  arsenic. 
and  to  a  less  extent  silver  and  phosphorus,  may  terminate  in 


760  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

chronic  gastritis  if  long  continued,  and  especiall}-  in  individ- 
uals with  a  sensitive  gastric  mucosa. 

In  its  secondar}-  form  chronic  gastritis  commonh-  accom- 
panies all  cases  of  chronic  passive  congestion  of  the  splanch- 
nic vessels,  and  is  habitualh-   seen  in  portal  obstruction,   in 
cirrhosis  of  the  liver,  and  in  valvular  and  muscular  lesions  of 
the  heart  when   a  state   of  incompetenc}-  has  been  reached. 
Gastritis  likewise  frequently  accompanies  other  organic  dis- 
eases of  the  stomach,  such  as  cancer  and  ulcer,  and  especial!}^ 
those  cases  complicated  by  pyloric  obstruction.     Again,  it  is 
practically  always  associated,  sooner  or  later,  Avith  constitu- 
tional diseases  of  long  standing,  prominent  among  which  may 
be  mentioned  nephritis,  tuberculosis,  syphilis,  diabetes  melli- 
tus,  pernicious  anemia,  Banti's  disease,  and  Addison's  disease. 
It  is  somewhat  of  a  paradox  that,  with  all  the  etiologic 
factors  so   commonK-   encountered,   one  may  yet  affirm  that 
gastritis   is   too   frequently   diagnosed   on   general   principles, 
rather  than  on  the  furnishing  of  pathologic  proof.     Neverthe- 
less, this  is  true,  and  no  such  diagnosis  can  be  a  sound  one 
unless  it  is  made  upon  the  examination  of  one  or  more  speci- 
mens of  gastric  contents  obtained  direct  from  the  stomach,  in 
both  the  fasting  and  digestive  periods.    The  direct  pathologic 
evidence  can  frequently  be  demonstrated  by  the  study  of  gas- 
tric sediments  obtained  from  the  fasting  morning  stomach, 
and  by  this  means  two  distinct  forms  of  gastritis  maj^  be 
classified  on  a  pathologic  basis. 

Hypertrophic  Glandular  Gastritis.  This  presents  the  clin- 
ical features  of  an  acid  gastritis,  and  here  the  pathologic  diag- 
nosis depends  upon  the  findings  of  fragments  or  flakes  of  gas- 
tric mucous  membrane  which  show  a  well-marked  hyperplasia 
of  the  glandular  elements,  and  in  which  the  individual  cells 
retain  good  staining  power.  This  applies  most  particularly  to 
the  base  or  fundic  portion  of  the-  glands,  whereas  the  cells 
.  toward  the  peripher}^  show  granular  protoplastic  degenera- 
tions, loss  of  staining  power,  and  absence  of  nuclei.  This  peri- 
pheral portion  frequently  desquamates  or  sloughs  oft',  and  is 
found  in  isolated  areas  in  the  microscopic  field.  The  inter- 
glandular  stroma  is  infiltrated  with  an  increased  number  of 
leucocytes ;  lymphocytes  predominate  in  the  more  chronic 
process,  while  the  polynuclear  varieties,  if  in  abundance,  will 


GASTRITIS.  761 

indicate  either  an  acute  gastritis  or  an  acute  exacerbation  of  a 
chronic  process,  provided  that  ulcer  and  cancer  are  excluded. 
Fragments  of  recovered  mucous  membrane  may  show  en- 
larged or  dilated  venules,  and  areas  of  pigmentation  and  con- 
g-estion  may  be  seen.  This  is  particularly  true  of  those  cases 
in  which  chronic  passive  congestion  of  the  splanchnic  vessejs 
is  an  etiologic  factor.  The  amount  of  mucus  is  usually  in- 
creased, although  this  is  not  as  invariable  a  finding  as  in  the 
pathologic  process  next  to  be  described. 

Atrophic  Gastritis.  This  type  presents  the  clinical  features 
of  a  subacid  or  anacid  gastritis,  and  here  recoverable  bits  of 
gastric  mucosa  show  a  considerable  diminution  in  the  number 
of  gastric  tubules,  and  a  marked  irregularity  in  their  distribu- 
tion ;  their  alignment  is  very  imperfect,  and  few  glands  can  be 
traced  from  fundus  to  neck.  The  cells  stain  poorly,  and  show 
mucoid  degenerations  of  the  protoplasm  with  marked  vacuo- 
lization and  a  notable  absence  of  cell  nuclei.  Frequently  gas- 
tric cells  are  seen  lying  in  the  lumen  of  the  tubule,  separating 
or  completely  broken  away  from  the  basement  membrane. 
Indeed,  all  of  the  epithelium  may  be  completely  denuded  from 
the  tubule,  leaving  simply  an  empty  space  in  the  mucosa, 
bounded  by  a  skeleton  framework  representing  the  basement 
membrane.  The  leucocytic  infiltration  is  usually  of  the  lym- 
phocytic type,  and  areas  of  venous  congestion  are  relatively 
infrequent.  In  the  more  chronic  stages  there  is  an  increase  of 
the  interstitial  connective-tissue  elements,  occurring  between 
the  tubules.  The  quantity  of  mucus  is  almost  invariably  in- 
creased, and  may  be  found  as  a  deep  layer  of  mucus  lightly 
attached  to  the  peripheral  portion  of  the  fragment  of  mucosa, 
or  as  islands  of  mucus  occurring  in  isolated  portions  of  the 
section. 

In  the  same  microscopic  field,  or  in  other  portions  of  the 
sediment  in  tlie  same  case,  may  be  found  practically  normal 
glandular  elements,  and  clinically  such  cases  usually  show 
normal  gastric  secretion.  This  may  furnish  a  plank  in  the 
argumentative  platform  that  the  findings  of  such  microscopic 
fragments  of  the  mucosa,  showing  various  pathologic  states, 
may  not  represent  a  true  picture  of  the  amount  of  organic 
damage,  or  the  degree  of  functional  power  of  the  stomach  as 
a   whole.      Nevertheless,    there    is    a   very    close    parallelism 


762  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

between  such  pathologic  evidence  obtained  by  sediment  study 
and  the  clinical  features  in  the  given  case. 

From  a  clinical  standpoint^  chronic  gastritis  may  be  classi- 
fied into  three  forms : 

1.  Gastritis  with  normal  or  increased  hydrochloric  acid 
and  enzyme  output  (gastritis  acida). 

2.  Gastritis  with  a  diminished  hydrochloric  acid  secretion, 
but  in  which  the  ferments  may  be  either  normal  or  moderately 
reduced  (gastritis  subacida). 

3.  Gastritis  with  total  failure  of  secretion  of  hydrochloric 
acid  and  the  ferments  reduced  (gastritis  anacida)  or  absent 
(achylia  gastrica).  Where  the  ferments  are  absent  it  is  of 
extreme  practical  importance  to  demonstrate  the  presence  or 
absence  of  the  proferments.  Their  continued  absence  indi- 
cates very  little  likelihood  of  restoring  the  gastric  secretion 
by  any  form  of  treatment. 

The  course  and  prognosis  will  naturally  depend  upon  two 
factors:  first,  the  efficiency  with  which  the  exciting  cause  is 
not  only  removed,  but  prevented  from  recurring;  and,  second, 
the  amount  of  pathologic  damage  inflicted  before  this  can  be 
accomplished.  Much  depends  upon  how  deeply  the  inflamma- 
tory lesions  have  penetrated  the  gastric  mucosa.  In  those 
affecting  the  more  peripheral  portion  the  outlook  is  much  more 
favorable,  inasmuch  as  the  glandular  elements  of  all  secret- 
ing membranes  have  a  tendency  to  regenerate  themselves 
from  below,  the  dead  or  functionless  cells  being  desquamated 
from  the  surface.  Not  only  is  the  pathologic  lesion  concerned 
in  the  depth  of  its  penetration  at  any  given  point,  but,  also 
with  its  lateral  extent  throughout  the  entire  secreting  surface. 
Naturally,  one  expects  that  the  hypertrophic  glandular  type 
(gastritis  acida)  would  be  much  the  more  likely  to  recover, 
after  the  exciting  cause  has  been  removed.  Such  is,  however, 
not  always  the  rule,  but  where  acid  symptoms  are  continuous, 
notwithstanding  appropriate  treatment,  one  will  do  well  to 
suspect  a  chronic  ulcer  or  a  state  of  vagotony.  In  those  cases 
with  normal  amounts  of  gastric  secretion  the  situation  is 
usually  more  simple  and  the  prognosis  better.  Where  the 
gastric  secretion  is  very  greatly  diminished  or  absent,  espe- 
cially the  latter,  and  supplemented  by  the  sediment  picture  of 
an  atrophic  gastritis,  one  can,  as  a  rule,  hold  out  little  hope 


GASTRITIS.  763 

of  restoring  the  secreting  functions  of  the  stomach  to  any 
point  that  will  aid  in  digestion,  and  the  aim  of  treatment 
should  be  directed  toward  protecting  the  intestines  and  con- 
serving their  function.  If  this  is  accomplished  the  patient 
will  continue  in  good  digestive  health,  notwithstanding  the 
absence  of  gastric  secretion. 

TREATMENT. 

The  treatment  can  be  divided  into  prophylactic  and  direct. 
The  teeth  should  be  put  into  good  order,  false  teeth  being 
provided  if  necessar}^,  and  thorough  mastication  should  be 
insisted  upon,  not  alone  that  the  food  may  be  properly 
brought  to  a  state  of  fine  division,  but  to  stimulate  the  flow 
of  saliva,  and  thus  to  secure  the  benefits  obtained  from 
salivary  digestion. 

The  habits  of  the  patient  should  be  critically  interrogated 
and  a  proper  hygiene  ordered — fresh  air,  home  hydrotherapy, 
and  a  proper  balance  of  rest  and  exercise.  In  short,  anything 
that  tends  toward  building  up  the  general  level  of  health  will 
bring  about  the  betterment  of  the  local  condition,  insure  the 
stomach  a  better  blood-supply,  and  aid  in  the  regenerative 
repair  of  the  pathologic  process.  Also,  in  the  way  of  direct 
removal  of  causative  factors,  all  irregularities  in  diet  should 
be  corrected,  both  as  to  the  kind  of  food  and  the  manner  in 
which  it  is  eaten.  For  the  business  man  or  woman  hasty 
lunch-counter  eating  should  be  forbidden ;  iced  drinks  or  very 
hot  soups  interdicted ;  mixed  alcoholic  beverages,  especially 
in  the  concentrated  forms,  forbidden,  except  that  in  certain 
cases  a  little  whisky,  well  diluted  in  a  glassful  of  water,  may 
be  taken  with  or  after  the  meal.  This  is  particularly  neces- 
sary in  the  chronic  g'astritis  due  to  alcoholism  in  which,  in 
exceptional  cases,  it  is  neither  safe  nor  possible  to  stop  the 
use  of  the  drug  abruptly.  Attendance  at  dinners,  public  or 
social,  where  rich  viands  in  many  courses  are  served,  should 
be  avoided;  the  use  of  tobacco  restricted,  especially  in  the 
hyperacid  form  of  gastritis ;  and  the  chewing  of  tobacco 
emphatically  forbidden. 

If  iron,  arsenic,  and  the  like,  or  the  habitual  use  of  laxa- 
tives have  been  contributing  etiologic  factors,  they  should  be 
promptly  discarded,  and  other  measures  adopted  in  their  place. 


764  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

The  direct  treatment  may  be  divided  into  dietetics,  mechan- 
ical, balneological,  electrical  and  medicinal. 

Dietetics.  The  general  principles  of  the  diet  will  vary- 
according  to  the  clinical  type  of  gastritis.  Hence,  the  need 
of  the  proper  classification  of  these  cases  after  determining 
the  state  of  the  gastric  functions,  both  secretory  and  motor. 
If  secretion  is  increased,  both  in  amount  and  concentration, 
the  diet  plan  elaborated  in  the  treatment  of  hyperchlorhydria 
(see  p.  764)  should  be  followed,  and  need  not  be  repeated 
here.  In  general,  a  mixed  diet  should  be  given,  the  chief 
essential  being  that  the  foods  are  bland  and  non-irritating, 
both  chemically  and  mechanically,  and  are  furnished  in  a  state 
of  fine  subdivision,  so  that  less  effort  will  be  needed  on  the 
part  of  the  stomach  to  grind  them  to  a  chyme  suitable  for 
entrance  into  the  intestines. 

For  the  first  few  days  it  is  probably  best  to  place  the 
patient  on  a  mixed  liquid  and  soft  diet,  in  order  to  give  the 
stomach  a  partial  rest.  The  number  of  meals,  and  the  amount 
of  food  eaten  at  each,  of  course,  depends  upon  whether  atony 
is  present  or  not.  In  this  event,  five  or  six  small  meals,  with 
a  restriction  of  fluid,  is  preferable  to  three  meals  of  the  cus- 
tomar)^  size.  In  uncomplicated  gastritis  the  motor  power  of 
the  stomach  usually  is  not  affected,  with  two  exceptions,  the 
hypomotility  associated  with  a  markedly  excessive  secretion 
of  mucus,  and  the  hypermotility  usually  accompanying  atrop- 
hic gastritis  or  the  achylic  states.  In  the  cases  in  which 
hydrochloric  acid  and  the  ferments  are  increased  salivary 
digestion  will  be  inhibited,  and  farinaceous  and  carbohydrate 
foods  will  be  less  well  borne  than  the  proteids.  AVhere  the 
hydrochloric  acid  and  the  ferments  are  reduced,  foods  rich  in 
the  native  proteins  or  dense  with  connective  tissue  will  be 
difficult  of  digestion,  and  only  the  softer  proteins,  such  as  fish, 
eggs  and  milk,  should  be  used,  and  the  diet  built  up  in  cereals, 
breadstuffs  and  vegetables.  AMien  the  secretion  of  hydro- 
chloric acid  and  the  ferments  is  totally  absent,  the  use  of 
proteins  must  be  greatly  reduced  or  entirely  discarded,  and 
the  patient  placed  very  largely  upon  a  vegetarian  diet.  In  this 
group  of  patients,  too,  it  may  be  permissible  to  use  some  of 
the  predigested  protein  foods,  such  as  somatose  and  laibose, 
which  are  mentioned  merely  as  examples. 


GASTRITIS.  765 

In  all  of  these  three  forms  the  caloric  value  of  the  diet  may- 
be built  up  to  any  point  desired  by  the  liberal  use  of  fats  in 
the  form  of  butter,  cream,  olive  oil  and  cheese. 

Where  constipation  is  present  buttermilk  is  often  helpful; 
likewise  honey,  cooked  fruits,  or  the  use  of  the  "fruit  for- 
mula," with  or  without  senna,  prepared  as  follows : 

Take  6  apples,  6  pears,  12  dates,  12  figs,  and  12  prunes. 

Chop  and  cut  up  finely  and  place  the  pulp  and  juice  in  a 
saucepan  with  1  quart  (liter)  of  water,  using  senna.  Tie  up 
the  senna-leaves  in  a  piece  of  cheesecloth,  and  place  them  in 
the  saucepan  with  the  fruit  mixture,  and  boil  mixture  slowly 
down  to  1  pint. 

Strain  through  gauze.  Bottle  and  keep  well  corked  in  a 
cool  place  (preferably  the  ice-box). 

For  use  take  1  tablespoonful  followed  by  a  glass  of  cold 
water  in  the  morning  on  rising  and  at  night  before  retiring. 

Salt  should  be  used  freely  in  subacid  and  anacid  gastritis, 
since  it  has  been  shown  to  stimulate  the  secretion  of  gastric 
juice,  and,  conversely,  its  use  should  therefore  be  reduced  in 
the  treatment  of  hyperacid  forms.  Similarly,  such  stimulating 
articles  as  salted  and  smoked  fish,  herring,  mackerel,  anchovy, 
caviar,  and  the  sharp  condiments,  which  are  definitely  contra- 
indicated  in  hyperacid  gastritis  may  find  a  place  in  the  dietary 
of  the  subacid  and  anacid  forms. 

The  following  diet  is  suggested  as  illustrative  of  the  gen- 
eral principles  stated  above,  and  is  particularly  the  diet  of 
choice  where  the  gastric  secretions  are  normal  or  diminished: 

On  arising,  a  cup  of  hot  beef-tea  made  from  any  good 
meat  extract  or  a  cup  of  hot  water  with  ^  a  teaspoonful 
(1.875  mils)  of  table  salt  in  it.  This  has  a  tendency  to  pro- 
mote gastric  secretion,  and  should,  therefore,  be  limited  to 
those  cases  with  diminished  secretion. 

Breakfast.  An  orange  or  a  grapefruit,  or  their  juice.  A 
saucerful  of  some  well-cooked  cereal,  such  as  farina,  or  cream 
of  wheat  may  be  eaten  with  cream  and  sugar.  One  or  2  eggs, 
lightly  boiled,  poached  or  scrambled,  and  some  crisp  breakfast 
bacon,  discarding  the  dense  connective-tissue  portions ;  or  a 
small  portion  of  salted  or  smoked  herring,  or  mackerel,  in 
raiarkedly  subacid  cases.  Stale  bread,  zwiebach,  or  dry  toast, 
with  a  liberal  amount  of  butter,  may  be  eaten  freely.     Brown, 


766  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

graham,  or  whole-wheat  bread  should  be  selected  if  the  patient 
is  constipated,  and  honey  or  marmalade  may  be  added.  But- 
termilk, if  constipated ;  otherwise,  a  cup  of  cocoa  with  cream 
and  sugar,  or  a  glass  of  milk.  Coffee  had  best  be  entirely 
avoided,  although  a  cup  of  weak  tea  is  permissible  if  espe- 
cially desired. 

Luncheon.  A  soup,  preferably  clam  or  meat  broth,  al- 
though cream  purees,  such  as  tomato,  potato,  asparagus  and 
pea,  are  permissible.  Creamed  chicken,  lamb-hash ;  good,  ten- 
der ham,  cut  fine  and  thoroughly  masticated ;  lamb-chop, 
creamed  fish,  or  oysters  in  any  form  except  fried.  A  thor- 
oughly cooked  mashed  or  baked  potato.  One  vegetable 
selected  from  the  list  outlined  for  dinner.  The  choice  of  any 
light  dessert,  such  as  milk,  rice,  tapioca,  junket,  cornstarch, 
blanc  mange.  Ice-cream,  ices,  and  iced  drinks  are  not  allowed. 
As  a  beverage  a  glass  of  milk  or  buttermilk,  or  a  glass  of  one 
of  the  medicated  mineral  waters,  discussed  later,  and  to  be 
selected  according  to  the  state  of  the  gastric  secretion.  Stale 
bread,  zwiebach,  or  dry  toast  with  butter.  All  foods  may  be 
well  seasoned,  and  simple  relishes  may  be  eaten. 

Dinner.  A  soup  as  at  luncheon.  A  small  piece  of  steak 
or  roast  beef,  chicken,  or  broiled  or  boiled  white  fish  with  but- 
ter sauce.  It  is  a  good  rule  that  if  meat  is  eaten  at  one  meal, 
fish  should  be  eaten  at  the  other,  and  the  use  of  meats  should 
be  somewhat  restricted,  in  proportion  to  the  lessened  gastric 
secretion.  ]\Iashed,  baked,  or  creamed  potatoes.  The  choice 
of  any  two  of  the  following  vegetables :  Creamed  or  boiled 
cauliflower,  spaghetti  or  macaroni,  well-cooked  rice  to  be 
eaten  with  butter,  spinach,  squash,  asparagus,  tender  string 
beans.  Any  vegetables  that  can  be  put  through  a  colander 
and  pureed  with  cream  are  permissible.  A  simple  salad  with 
French  dressing.  The  same  choice  of  desserts  as  at  luncheon. 
The  same  choice  of  beverages  with  the  additional  choice  of  a 
little  whisky,  well-diluted  with  water,  or  a  glass  of  good  claret 
or  Rhine-wine.  Champagne  and  all  aerated  wines,  and  all 
malt  beverages,  such  as  beer  and  ale,  are  distinctly  injurious 
and  should  be  avoided.  Foods  may  be  w^ell  seasoned,  and  sim- 
ple relishes  eaten. 

If  a  gain  in  weight  is  desired,  midmeal  feedings  mav  be 
selected  from  the  following: 


GASTRITIS.  767 

Six  or  8  ounces  of  milk  with  1  raw  egg  well-beaten  in, 
to  which  nutmeg  may  l)e  added.  This  may  be  still  further 
richened  by  adding-  one-third  cream,  and  may  be  flavored  with 
vanilla  or  chocolate,  or  any  fruit  juice  if  there  is  a  distaste  for 
milk.  Buttermilk,  kefir,  koumiss,  or  matzum  may  be  chosen 
instead.  A  few  salted  crackers,  liberally  buttered,  should  be 
eaten. 

These  midmeal  feedings,  likewise,  apply  to  such  cases  of 
gastritis  as  are  complicated  by  atony,  remembering  however, 
that  in  such  instances  the  use  of  liquids  with  meals  is  to  be 
avoided. 

In  cases  of  anacidity  the  proteid  content  of  the  above  menu 
must  be  greatly  reduced  or  omitted.  The  proper  dietary  to 
be  followed  in  anacidity  will  be  found  in  the  discussion 
on  Dietetics.     (See  p.  764.) 

Mechanical  Treatment.  Lavage  stands  first  and  foremost 
as  an  efficient  agent  in  the  mechanical  treatment  of  uncompli- 
cated gastritis,  but  its  use  should  be  limited,  with  one  excep- 
tion, to  those  cases  which  show  an  overabundant  secretion  of 
mucus  that  is  intimately  mixed  with  and  surrounds  the  food 
particles  in  a  very  tenacious  mass,  and  thus  not  only  prevents 
the  ready  admixture  of  food  with  the  gastric  juices,  but  like- 
wise delays  the  exit  of  the  chyme.  The  one  exception  is  in 
those  cases  of  hyperacid  gastritis  in  which  the  secretion  of 
mucus  is  low,  and  in  which  the  mucous  membrane  is  sub- 
jectively sensitive  to  the  burning  and  corroding  action  of  the 
gastric  juice.  In  such  instances  the  mucus  is  protective,  and 
its  secretion  should  be  encouraged  by  lavaging  with  stimulat- 
ing medicated  solutions  such  as  silver  nitrate  in  a  dilution  of 
1 :  3000  to  1 :  1000. 

Lavage  in  all  cases  should  be  practised  for  a  short  period 
only,  and  if  definitely  satisfactory  results  cannot  be  accom- 
lished  in  three  or  four  weeks'  time,  its  further  exhibition  should 
be  discontinued.  Lavage  serves  to  cleanse  the  stomach  and 
rid  it  of  mucus,  which  is,  often  thick  and  ropy,  and  plugs  up 
the  lumen  of  the  secreting  tubules ;  it  further  stimulates  the 
secreting  power  of  the  oxyntic  and  enzymotic  cells,  and,  in 
addition,  in  neurotic  patients  frequently  creates  a  sense  of 
general  well-being  in  a  purely  psychic  manner.  The  best 
results  from  lavasre  are  seen  in  those  cases  of  eastritis  with 


768  DISEASES    OF   THE   DIGESTIVE    SYSTEM. 

diminished  secretion  and  increased  mucus.  In  anacidity  and 
dry  achylia  less  can  be  accomplished,  since  the  pathologic 
process  is  more  extensive,  although  patients  aver  that  they 
feel  greatly  refreshed  after  this  internal  toilet.  Where  atony 
is  a  complicating  factor,  and  there  is  some  degree  of  stagna- 
tion and  fermentation,  lavage  is  doubly  indicated,  but  should 
be  practised  with  caution.  Not  more  than  400  mils  (13.34 
ozs.)  of  the  lavaging  fluid  should  be  introduced  into  the 
stomach  at  any  one  time,  and  care  should  be  taken  that  the 
amount  recovered  equals  that  introduced.  In  gastritis  with 
atony  the  best  results  are  obtained  where  electrical  treat- 
ments are  combined  with  lavage.  (See  p.  773.)  The  selec- 
tion of  the  proper  time  for  lavage  is  important.  By  far  the 
best  time,  in  most  cases,  is  to  wash  the  stomach  in  the  fasting 
state,  before  breakfast.  This  serves  to  cleanse  the  stomach 
of  its  accumulated  mucus,  and  to  prepare  it  for  the  day's  work. 
It  is  a  time,  however,  that  is  more  practical  for  hospital  cases 
than  for  those  who  are  to  be  treated  in  the  office,  the  more 
convenient  time  for  the  latter  being  about  the  noonday 
period,  or  from  5  to  6  o'clock  in  the  evening,  which  usually 
means  one  hour  before  the  next  meal  and  four  or  five  hours 
after  the  last  one.  In  gastritis  lavage  need  never  be  practised 
oftener  than  once  a  day,  and  this  for  never  more  than  the  first 
week,  gradually  reducing  the  number  of  treatments  to  every 
other  day,  then  every  third  day  for  a  total  period  of  not  more 
than  three  or  four  weeks.  The  temperature  of  the  lavaging 
fluid  should  be  from  100°  to  105°  F.  (37.8°  to  40.4°  C),  where 
a  cleansing  effect  is  desired.  In  the  treatment  of  an  associated 
atony,  alternate  hot  and  cold  douches,  by  means  of  the  double 
tank  (Leube-Rosenthal  method),  tend  to  improve  the  motor 
defects.  The  amount  of  lavaging  fluid  introduced  at  any  one 
time  should  not  exceed  500  mils  (16.67  ozs.)  before  a  similar 
amount  is  recovered,  and  in  atony,  as  above  stated,  400  mils 
(13.34  ozs.)  should  be  the  highest  limit.  As  to  the  selection 
of  the  lavaging  fluid,  the  choice  is  a  wide  one.  Numerous 
medicated  solutions  have  been  recommended  from  time  to 
time,  but  aside  from  the  few  that  will  be  discussed,  the  writer 
has  seen  no  advantageous  results  from  their  use  which  could 
not  be  achieved  by  normal  salt  solution  or  plain  water  alone. 
In  chronic  gastritis  with  increased  mucus,  lavage  with  an 
alkaline  solution  is  by  far  the  best,  inasmuch  as  this  serves 


GASTRITIS.  769 

to  liquefy  and  dislodge  the  tenaciously  adherent  mucus  from 
the  gastric  mucosa. 

The  best  alkaline  solution  is  soda  bicarljonate  in  a  strength 
of  1  tablespoonful  to  each  quart  (16  Gms.  to  each  1000  mils), 
or  lime-water,  1  ounce  to  each  quart  (32  Gms.  to  each  1000 
mils).  After  lavaging  with  this,  a  solution  of  the  tincture  of 
hydrastis,  1  tablespoonful  to  each  quart  (16  Gms.  to  each 
1000  mils),  or  fluidextract  of  hydrastis,  1  to  2  teaspoonfuls  to 
each  quart  (4  to  8  Gms.  to  each  1000  mils),  seems  to  act 
favorably  as  an  astringent,  and  to  a  great  extent  prevents  fur- 
ther secretion  of  mucus.  This  -is  particularly  helpful  in  gas- 
tromyxorrhea.  In  gastritis  with  marked  subacidity  one  may 
use  pure  hydrochloric  acid,  1  teaspoonful  to  1  quart  (4  mils 
to  1000  mils),  which  is  stimulating  to  the  glandularis,  and  is 
also  an  excellent  antiseptic.  This  solution,  however,  should 
not  be  used  except  in  the  later  weeks  of  treatment  when  the 
excess  of  mucus  secretion  has  been  diminished.  In  chronic 
gastritis  of  the  advanced  achylic  types,  even  in  the  presence 
of  an  excess  of  mucus,  lavage  seldom  does  good,  and  may 
be  harmful.  This  does  not  apply,  however,  to  the  psychic 
achylias.  In  hyposecretion,  associated  with  hypomotility, 
when  not  organic  or  malignant,  lavage  for  short  periods  with 
pure  hydrochloric  acid,  as  above,  or  with  a  1 :  1000  silver 
nitrate  solution  serves  to  stimulate  the  glandularis.  As  a 
bland  alkaline  solution  the  writer  prefers  the  liquor  antisepti- 
cus  alkalinus,  and  makes  a  practise  of  terminating  lavage  in 
hyperacid  cases  by  introducing,  through  the  stomach-tube,  1 
ounce  (30  mils)  of  this  solution,  diluted  with  an  equal  quan- 
tity of  water,  and  leaving  it  in  situ. 

In  hypersecretion  lavage  is  harmful  with  the  following 
three  exceptions : 

1.  In  hypersecretion  or  hyperacidity  where  there  is  little 
or  no  mucus  present,  lavage  with  a  silver  nitrate  solution,  as 
stated  above,  will  give  marked  subjective  relief  by  acting  as 
an  irritating  stimulant  to  the  glandularis,  by  increasing  the 
amount  of  mucus  secretion,  which  serves  as  a  protectant  from 
the  irritating  gastric  juice.  This  subjective  relief  continues, 
even  though  the  chemical  analyses  show  a  higher  acidity  in 
the  end  than  was  present  in  the  beginning,  provided  that  the 
mucus  secretion  has  been  relatively  raised. 


770  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

2.  In  gastritis  with  hypersecretion,  when  complicated  by 
fermentation,  lavage  will  prove  of  benefit,  and  in  such  cases 
the  writer  prefers  to  use  a  weak  solution  of  potassium  per- 
manganate in  a  strength  of  1 :  10,000  to  1 :  15,000. 

3.  In  the  irritative  form  of  gastritis  (hypertrophic  gland- 
ular gastritis,  gastritis  acida)  a  short  exhibition  of  the  alkaline 
lavage  solutions  above-mentioned  often  secures  good  symp- 
tomatic results. 

In  lavaging  all  cases  of  gastritis  in  the  fasting  state  the 
total  amount  of  lavaging  fluid  needed  will  seldom  exceed  2 
quarts  (2000  mils).  This  amount  of  lavage  can  be  easily  car- 
ried out  by  means  of  the  Leube-Rosenthal  irrigating  method 
in  from  three  to  five  minutes,  depending  upon  the  tonicity  of 
the  gastric  muscles,  4\'hich  largely  determines  the  rate  of  the 
return-flow.  Where  solutions,  such  as  silver  nitrate,  potas- 
sium permanganate,  or  pure  hydrochloric  acid  are  used,  they 
should  be  followed  by  a  gastric  douche  with  plain  water.  At 
the  termination  of  lavage  various  mechanical  sedatives  to  the 
stomach,  such  as  cerium  oxalate,  bismuth  subcarbonate,  or 
syrup  of  acacia,  may  be  introduced  through  the  tube.  Like- 
wise, this  is  an  excellent  and  easy  method  of  administering 
castor  oil,  should  its  use  be  indicated. 

The  direct  treatment  of  the  gastric  mucosa  by  means  of 
gastric  sprays,  powder  insufflations,  and  the  like,  by  means  of 
specially  constructed  apparatus  has  not  proven  particularly 
beneficial  in  the  writer's  experience.  It  is  almost  needless  to 
state  that  the  proper  dietetic  and  hygienic  management  of  the 
patient  is  quite  as  important  as  the  local  treatment  of  the 
stomach. 

Balneological  Treatment.  The  use  of  medicated  mineral 
waters  is  of  considerable  value  in  assisting  the  treatment  of 
the  various  forms  of  chronic  gastritis,  although  in  the  writer's 
opinion  this  is  by  no  means  one  of  the  therapeutic  essentials. 
These  mineral  waters,  according  to  their  type,  ser\'e  either  to 
stimulate  the  gastric  glandulature  toward  an  increased  secre- 
tion, or  partly  to  neutralize  the  overproduction  of  acids. 
With  this  object  in  view,  the  particular  water  prescribed  for 
each  case  should  be  intelligently  selected.  Unfortunately,  it 
is  true  that  this  particular  field  of  natural  therapy  has  not 
been  sufflcientlv  studied  in  its  connection  with   the  various 


■     GASTRITIS.  771 

springs  in  this  country.  When  this  has  been  systematically 
undertaken  it  is  quite  likely  that  some  of  our  natural  waters 
will  rival  or  excel  in  their  effects  those  of  the  most  exploited 
European  spas.  This  is  a  most  timely  necessity,  inasmuch  as 
the  present  European  holocaust  will,  for  some  years  to  come, 
affect  the  popularity  and  accessibility  of  most  of  the  foreign 
water-cures. 

While  the  medicinal  value  of  these  waters  is  considered  a 
therapeutic  entity  by  European  writers,  and  occupies  a  large 
space  in  their  literature,  the  use  of  the  imported  waters,  or  of 
their  desiccated  salts,  has  not  proven  brilliantly  efficacious  in 
the  writer's  experience,  and  it  is  doubtless  a  fact  that  the 
beneficial  results  obtained  by  residence  at  such  foreign  spas 
comes  from  the  freedom  from  business  and  social  cares,  from 
the  outdoor  exercise,  from  the  enforced  regularity  in  habits 
of  eating,  drinking  and  sleeping,  from  the  abstinence  in  alco- 
holic beverages,  interdicted  at  such  places,  and  from  the  con- 
stant flushing  of  the  kidneys  and  skin  that  naturally  would 
follow  drinking  of  large  amounts  of  these  waters,  rather  than 
from  any  essential  indispensable  medicinal  value  of  the  waters 
themselves. 

As  a  rule,  motor  defects  contraindicate  the  use  of  mineral 
waters,  especially  those  of  the  aerated  type.  Particularly  is 
this  important  in  the  motor  defect  due  to  atou}^,  and  patients 
thus  affected  should  be  cautioned  not  to  drink  more  than  one 
glass  at  a  time,  and  this  at  a  midmeal  period,  or  at  least,  not 
within  two  hours  after  the  last  meal.  Those  patients  who 
are  of  a  nervous  disposition,  or  who  are  greatly  run  down 
should  not  be  given  purgative  waters,  or  at  least,  never  in 
amounts  sufficient  to  cause  watery  movements.  Where  there 
are  no  motor  errors,  and  secretory  defects  alone  have  to  be 
considered,  the  selection  of  the  water  to  be  used  mav  be 
determined  by  the  following  facts : 

In  anacid  or  achylic  states  the  saline  waters  which  con- 
tain chiefly  sodium  chloride  and  carbon  dioxide  are  indicated. 
The  best  of  the  European  waters  for  this  purpose  are  those 
of  the  Rokoczy  Spring  at  Kissingen.  The  salts  from  this 
spring  have  been  carefully  studied,  and  the  artificial  substitute, 
the  Sal  Kissingense  Factitium,  has  been  introduced  into  our 
newer  formulary  with  a  dosage  of  1   gram  to  a  glassful  of 


7'?2  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

■water  (15  grs.  to  8  ozs.).  Other  European  springs  which 
enjoy  a  good  reputation  for  the  treatment  of  these  conditions 
are  Homburg  (the  Elizabeth  Quelle  Spring;,  \Mesbaden 
(Kochbrunner  Spring)  and  Ems.  In  this  country  the  Con- 
gress Spring  at  Saratoga  has  very  much  the  same  chemical 
composition  as  that  of  the  Kissingen  water.  The  action  of 
these  waters  is  said  to  dissolve  gastric  mucus,  to  augment  the 
secretion  of  hydrochloric  acid,  and  to  improve  the  appetite. 
Experimental  work  upon  dogs  in  the  laboratories  of  Pawlow 
and  others  has  shown  that  the  gastric  secretion,  after  the 
introduction  of  these  saline  waters,  has  been  from  50  to  7}i 
per  cent,  greater  than  with  that  obtained  with  ordinary  water. 
In  psychic  achylia  reports  have  been  published  of  a  re-estab- 
lishment of  hydrochloric  acid  after  a  sojourn  at  Kissingen  or 
at  Saratoga  Springs. 

The  water  should  be  given  cold  in  atonic  constipation, 
warm  if  there  is  spastic  constipation,  and  hot  if  there  is  diar- 
rhea. Not  more  than  one  g-lassful  should  be  given,  and  on 
an  empt)^  stomach,  about  one  hour  before  the  meal.  The  best 
results  are  obtained  in  those  cases  of  subacid  gastric  catarrh 
where  hydrochloric  acid  is  still  present,  although  in  dimin- 
ished amount,  and  where  the  mucus  secretion  is  increased. 

For  patients  in  whom  the  gastric  secretion  is  high,  with 
an  overproduction  of  mucus,  the  alkaline  mineral  waters  are 
to  be  selected.  Among  these  the  following  may  be  recom- 
mended:  Carlsbad  water,  which,  in  addition  to  being  alkaline, 
has  a  laxative  action,  and  is,  therefore,  useful  in  cases  with 
constipation.  When  this  is  present  the  waters  should  be 
taken  cold.  The  natural  water  from  the  spring  has  a  tem- 
perature of  144.8°  F.  (63°  C),  and  the  hotter  it  is  taken  the 
less  effect  it  seems  to  have  upon  the  bowels,  and  especial!}^  is 
this  true  in  atonic  constipation.  Where  the  original  Carlsbad 
water  cannot  be  secured,  the  desiccated  salts,  prepared  and  dis- 
pensed by  Eisner  and  ^lendelsohn,  ma}^  be  substituted,  or  our 
pharmacopoeial  preparation,  the  sal  caroliniim  factitium,  may 
be  used.  In  this  countn.-  the  water  of  the  Bedford  Springs  is 
very  similar  in  its  chemical  composition  to  that  of  Carlsbad. 
Both  contain  sodium  sulphate,  sodium  chlorid,  sodium  car- 
bonate, and  free  carbon  dioxid.  Xone  of  these  laxative 
waters  should  be  given  in  sufficient  amount  to  cause  diarrhea. 


GASTRITIS.  yiZ 

As  a  general  rule,  one  glassful  is  to  be  taken  hot,  on  an  empty 
stomach,  one-half  hour  before  breakfast,  and  should  this  not 
cause  diarrhea,  half  a  glass  may  be  taken  before  luncheon  and 
before  dinner.  Pluto  (French  Lick  Springs)  and  Mount 
Clemens  waters  in  this  country,  and  the  Hunyadi  Janos  and 
Apenta  waters  abroad,  are  somewhat  too  drastic  in  their 
purgative  laxative  effect  to  be  serviceable  in  the  treatment  of 
hyperacid  gastritis. 

The  Carlsbad  treatment,  given  hot  and  in  small  doses,  is 
indicated  in  hyperacid  gastritis  with  constipation,  in  chronic 
gastric  and  duodenal  ulcers,  and  in  chronic  ileocolitis.  It 
should  never  be  given  in  functional  gastrointestinal  diseases, 
even  though  it  may  be  otherwise  indicated,  where  the  etiol- 
ogic  factor  can  be  traced  to  a  disturbance  of  the  nervous  sys- 
tem.    It  invariably  makes  nervous  patients  worse. 

In  those  patients  in  whom  constipation  is  not  a  feature  the 
best  waters  to  combat  the  acidity  are  Celestins  Vichy  (or 
our  official  substitute,  the  sal  vichianiim  factitium),  Victoria 
Brunnen,  or,  in  this  country,  the  water  from  the  Hathorn 
Spring  at  Saratoga.  These  waters  all  contain  sodium  bicar- 
bonate and  carbon  dioxid.  Where  there  is  an  associated 
atony  the  waters  containing  carbon  dioxid  are  contraindi- 
cated.  Where  anemia  is  present,  Levico,  Mild,  or  Schwal- 
bacher  waters  may  be  used. 

Electrical  Therapy.  The  use  of  electricity  during  the  past 
five  years  has  come  rapidly  to  the  fore  in  the  treatment  of 
gastrointestinal  diseases,  and  in  chronic  gastritis,  as  a  supple- 
ment to  dietetics  and  lavage,  it  has  proved  a  valuable  addition 
to  our  therapeutic  armamentarium. 

There  is  still  considerable  controversy  between  physiolog- 
ists and  clinicians  as  to  what  we  should  ascribe  the  clinical 
improvement  following  the  use  of  electricity,  the  favorable 
evidence  of  which  is  rapidly  accumulating.  The  physiologists 
have  tenaciously  held  the  opinion  that  the  glandulature  and 
musculature  of  the  stomach  will  not  respond  to  an  electrical 
current,  and  that  the  beneficial  results  clinicallv  observed 
must  be  due  to  psychic  effects  alone.  With  this  view  the 
writer  emphatically  disagrees.  With  an  intragastric  electrode 
in  situ  and  an  extragastric  electrode  placed  externally  at  any 
point  of  the  body,  but  preferably  over  the  third  to  the  eighth 


774  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

thoracic  vertebra,  and  the  current  turned  on,  it  can  be  easily 
demonstrated  clinically  that  the  current  is  completed  by 
observing  the  gastric  contractions  produced,  which  can  be 
readily  palpated  through  the  abdominal  w^all,  and  which  can 
often  be  subjectively  felt  by  the  patient.  Furthermore,  it  has 
been  demonstrated,  by  means  of  fluoroscopic  examinations  on 
patients  being  so  electrically  treated,  that  there  is  not  only  a 
rhythmical  contraction  of  the  viscus,  but  an  increase  of  the 
peristaltic  waves. 

These  treatments  may  be  given  both  intragastrically  and 
by  the  percutaneous  route,  but  the  former  is  very  much  the 
more  efficient.  During  the  earlier  days  of  its  use  there  was 
some  uncertainty  as  to  which  types  of  current  should  be  used 
to  overcome  the  different  secretory  and  motor  defects,  but  the 
trend,  of  opinion  now  is  that  the  faradic  current  is  useful  for 
retoning  gastric  musculature,  with  or  without  atonic  ectasia, 
where  the  pathologic  defect  is  not  so  great  as  to  prevent 
respiration  of  muscle  tone.  This  current,  likewise,  stimulates 
an  increase  of  gastric  secretion.  It  is  useful,  too,  in  cases  of 
abnormal  relaxation  of  the  pylorus  and  the  cardia.  The  gal- 
vanic current  seems  to  act  particularly  well  as  a  sedative  for 
abnormal  disturbances  of  gastric  sensation,  and  is  partic- 
ularly efficacious  in  the  treatment  of  gastralgias  and  hyper- 
esthesias of  nervous  origin.  It  is  generally  conceded  to  be 
the  current  of  choice  in  cases  of  hyperacidity  or  hypersecre- 
tion. In  nervous  patients,  with  secretory  or  motor,  rather 
than  sensory  defects,  the  faradic  current  exercises  a  psychic 
effect  that  is  often  not  accomplished  by  the  galvanic.  More 
recently  the  sinusoidal  current  has  been  developed  and  per- 
fected, and,  in  the  writer's  opinion,  is  the  current  of  choice 
in  the  treatment  of  atonic  stomachs,  inasmuch  as  it  guards 
against  overfatigue  of  the  gastric  muscle  on  account  of  the 
long  period  of  relaxation  between  contractions. 

For  the  treatment  of  subacid  gastritis,  after  the  inflamma- 
tory phenomena  have  been  controlled,  and  the  diminished 
secretion  alone  remains,  or  in  cases  of  delayed  secretion,  as 
diagnosed  by  fractional  gastric  analyses,  the  writer  has  had 
some  brilliant  results  with  the  use  of  the  Bergonie  apparatus 
modified  by  Naegleschmidt.  This  device  delivers  an  inter- 
rupted current  of  the  sinusoidal  type,  which  can  be  made  as 


GASTRITIS.  775 

slow  or  fast  as  desired.  It  is  especially  useful  where  there  is 
an  associated  aton}^  or  an  atonic  ectasia,  provided  the  patho- 
logic defect  is  not  too  extreme  (paralytic  atony).  The  intra- 
gastric method  gives  considerably  quicker  results,  although 
satisfactory  improvement  will  follow  the  extragastric  route. 
With  the  Bassler  electrode  the  ordinary  patient  does  not 
object  to,  and  often  prefers,  the  intragastric  method.  It  can 
be  easily  passed  with  a  little  initial  swallowing  assistance  on 
the  part  of  the  patient,  and  is  quite  comfortable  when  once 
beyond  the  glottis.  In  subacid  cases  the  positive  pole  is 
attached  to  the  intragastric  electrode,  as  it  causes  less  elec- 
trolysis, and  the  extragastric  electrode,  in  the  form  of  a  hand 
sponge,  is  attached  to  the  positive  pole.  This  electrode  may 
be  either  a  large  one,  6  inches  (15.24  cm.)  long  by  3  inches 
(8  cm.)  wide,  which  can  be  strapped  in  position  over  the 
vertebral  region  from  the  third  to  the  eighth  thoracic  verte- 
bra, from  which  point  the  sympathetic  nerve-supply  to  the 
stomach  emerges  from  the  spinal  cord,  or  a  smaller  sponge 
electrode  may  be  carried  down  the  sides  of  the  neck  and  over 
the  sternomastoid  muscle,  'to  stimulate  the  pneumogastric 
nerve  lying  beneath  it.  Where  there  is  an  associated  relaxa- 
tion of  the  abdominal  musculature  the  external  electrode  may 
be  placed  over  the  abdomen  for  a  fewl  minutes  of  each  seance, 
to  secure  abdominal  contractions.  Where  the  intragastric 
method  is  employed  the  duration  of  each  treatment  should 
not  exceed  ten  minutes,  although  longer  sessions  may  be 
given  by  the  percutaneous  route,  and  the  writer  prefers  to 
interrupt  the  treatment  every  two  minutes  and  give  an  inter- 
val of  one  minute  rest.  Where  the  sinusoidal  or  galvanic 
currents  are  used  intragastrically  the  strength  of  the  current 
should  not  exceed  15  to  20  milliamperes,  and  the  faradic  cur- 
rent should  be  well  within  the  limits  of  tolerance  of  the 
patient.  Treatments  may  be  given  every  day  for  a  week, 
every  other  day  for  a  week,  and  then  at  intervals  of  twice  or 
once  a  week,  dependent  upon  the  progress  of  the  case.  In 
gastric  atony,  .to  secure  satisfactory  results  in  the  way  of 
permanency,  the  treatments  should  be  continued  for  two  or 
three  months.  They  should  always  be  given  on  an  empty 
stomach,  preferably  before  breakfast,  or  three  or  four  hours 
after  the  last  meal.     In  the  latter  case  it  is  better  to  lavage 


77^  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

the  stomach,  after  which  200  to  400  mils  (6.67  to  13.34  ozs.) 
of  water,  or,  preferably,  normal  salt  solution,  may  be  left  in 
the  stomach  to  serve  as  a  conductor  for  the  electricity  and 
to  prevent  burning  of  the  mucous  membrane  from  contact 
with  the  electrode.  Should  lavage  not  be  performed,  the 
patient  should  drink  one  or  two  glasses  of  water,  which  will 
serve  a  similar  purpose. 

Medicinal  Treatment.  When  the  dietetic  and  physical 
methods  of  treating  the  various  forms  of  gastritis  have  been 
properly  carried  out,  there  usually  remains  but  little  indica- 
tion for  the  use  of  chemical  therapy,  and  there  is  no  doubt 
that  in  any  case  the  use  of  the  methods  outlined  above  are 
far  more  beneficial  than  the  indiscriminate  use  of  drugs.  Espe- 
cially is  this  true,  as  is  commonly  the  case,  when  various 
chemical  agents  are  prescribed  before  a  knowledge  of  the  gas- 
tric secretory  and  motor  state  of  the  patient  has  been  learned. 
Careful  and  complete  gastric  analyses  should  be  made  in 
every  patient,  and  test-meals  should  be  used  to  determine 
motor  as  well  as  secretory  defects.  Furthermore,  in  many 
cases  fractional  gastric  analyses  will  be  necessary  to  properly 
interpret  the  question  of  disordered  secretion.  In  any  form 
of  gastritis  with  an  associated  motor  defect  in  which  the 
stomach  does  not  fully  empty  itself  during  the  time  interval 
between  meals,  and  the  stomach  still  contains  a  miscellaneous 
chyme,  tenaciously  bound  together  by  mucus,  and  with  mucus 
densely  adherent  to  the  gastric  mucosa,  it  is  unreasonable  to 
believe  that  any  medicinal  agent  designed  to  take  efifect  upon 
the  gastric  mucous  membrane,  or  to  be  absorbed  through  the 
gastric  mucous  membrane,  can  possibly  do  so  when  con- 
fronted by  this  mechanical  impediment. 

Many  badly  disordered  stomachs  are  made  worse  by  the 
indiscriminate  or  irrational  use  of  chemical  agents.  The  first 
requisite  is  that  the  stomach  should  be  cleansed  of  its  mucus 
before  medicinal  agents  can  be  made  effective.  When  this 
has  been  accomplished,  and  when  gastric  chemistry  has  been 
determined,  there  are  certain  drugs  which  may  be  prescribed, 
alone  or  in  combination,  according  to  the  indications  peculiar 
to  the  individual  case. 

Where  there  is  hypersecretion  or  hyperacidity  the  use  of 
antacid  powders  may  be  given  after  meals,  just  before  the 


GASTRITIS.  77/ 

highest  point  of  secretion  has  been  reached.  Bicarbonate  of 
soda  forms  the  important  foundation  for  all  such  powders. 
If  there  be  an  associated  constipation  the  light  oxid  of  mag- 
nesia may  be  added  as  in  the  following  prescription : 

!?■  Magnesia  uste   gr.  x   (0.6  Gm.) . 

Sodii  bicarbonatis   gr.  xx  (1.2  Gms.). 

Ft.  chart,  no.  j. 

S. :     Suspend  the  powder  in   1   ounce    (30  mils)    of 

water,   and  take  after  meals  and  at  the  time 

directed. 

In  patients  with  g'astric  hyperesthesia  or  gastralgia  the 
use  of  the  mechanical  sedatives,  such  as  bismuth  and  cerium 
oxalate,  may  be  employed.  The  following  prescription  can 
be  recommended: 

I^.  Cerium  oxalatis   gr.  v  (0.3  Gm.). 

Bismuthi  subcarbonatis   gr.  x  (0.6  Gm.). 

Soda  bicarbonatis    gr.  xx   (1.2  Gms.). 

Ft.  chart,  no.  j. 

S. :  Suspend  the  powder  in  1  ounce  (30  mils)  of 
water,  and  take  after  meals  and  at  the  time 
directed. 

Where  bismuth  is  indicated  as  a  mechanical  sedative  and 
hyperacidity  is  not  present,  bismuth  subnitrate  is  better  than 
bismuth  subcarbonate,  and  should  be  given  before  meals 
rather  than  after  meals,  and  in  somewhat  large  doses.  It  is 
often  good  practice  to  give  a  single  dose  of  30  to  50  grains 
(1.8  to  3.0  Gms.)  suspended  in  half  a  glassful  of  water  on  a 
fasting  stomach  before  breakfast.  This  will  often  control 
gastric  hyperesthesia  for  the  day.  In  cases  with  hypersecre- 
tion the  use  of  silver  nitrate  by  means  of  the  nine-day  cycle, 
as  recommended  by  Lockwood  (see  page  708),  is  often  bene- 
ficial, provided  that  the  hypersecretion  is  of  a  functional  type. 
As  already  stated,  where  the  mucous  secretion  is  low  and  the 
gastric  acidity  is  hig'h,  the  use  of  a  silver  nitrate  lavage  in  a 
dilution  strength  of  1 :  3000  to  1 :  1000  is  a  useful  procedure, 
or  the  tincture  of  belladonna  may  be  given  before  meals, 
starting  with  5  drops  and  increasing  a  drop  each  dose,  but 
keeping  well  within  the  physiologic  tolerance  of  the  patient. 
This  should  not  be  continued  for  too  long  a  period. 


778  DISEASES   OF   THE   DIGESTIVE   SYSTEM.- 

In  gastritis  with  diminished  or  absent  secretion  the  use  oi 
hydrochloric  acid  is  logically  indicated. 

Where  the  hydrochloric  acid  is  merely  diminished  the 
dilute  hydrochloric  acid  may  be  given  in  a  dosage  starting  with 
10  drops  (0.6  mil)  and  increasing  1  drop  (0.06  mil)  each  time 
the  medicine  is  taken  until  25-drop  (1.5  mils)  doses  have  been 
reached,  and  thereafter  maintaining  this  maximum.  It  should 
be  given  well  diluted  in  4  to  8  ounces  (120  to  240  mils)  of 
water,  one-third  to  be  taken  at  the  beginning  of  the  meal, 
one-third  at  the  close  of  the  meal,  and  the  balance  one-half 
hour  later.  It  should  be  taken  through  a  glass  tube.  If  there 
is  diminished  appetite  one  may  add  to  the  foregoing  1  tea- 
spoonful  (3.75  mils)  of  a  stomachic,  of  which  the  writer  pre- 
fers either  the  compound  tincture  of  gentian  or  the  fluid- 
extract  of  condurango.  The  administration  of  hydrochloric 
acid,  in  addition  to  its  effect  as  a  partial  aid  in  gastric  diges- 
tion, fulfils  an  important  purpose  in  stimulating  the  secretion 
of  pancreatic  juice. 

Another  way  of  administering  hydrochloric  acid  is  by 
means  of  acidulated  milk,  which  can  be  prepared  by  adding 
to  a  glassful  of  milk  sufficient  dilute  hydrochloric  acid  as  to 
cause  a  reaction  for  free  acid  to  Congo  paper.  In  constipated 
cases,  due  to  hepatic  torpor,  not  only  may  the  gastric  secre- 
tion be  stimulated,  but  also  the  flow  of  bile  increased  by  the 
use  of  the  dilute  nitrohydrochloric  acid,  in  a  dosage  of  from 
3  to  5  minims,  well  diluted  and  taken  through  a  glass  tube 
after  the  meal.  For  this  purpose,  and  as  a  tonic,  for  those 
cases  of  gastritis  secondary  to  a  prolonged  acute  infection,  the 
following  prescription  of  Hare's  is  an  excellent  one : 

IJ  Acidi  nitrohydrochlorici 

dilutae f 3j  vel.  f ^i j  (4-8  mils) . 

Tincture  nucis  vomicce...    f3j   (4  mils). 
Tinct.  cardamomi  comp..    fSij  (60  mils). 
Tincture  gentianae 

compositae  q.  s.  ad   f.§iv  (120  mils). 

M.     S. :     One  teaspoonful    (4  mils)    is  to  be  taken 
well  diluted  with  water  after  meals. 

Aside  from  its  effect  as  a  gastric  stimulant  and  as  an 
excitant  of  the  hormone  secretion,  it  is  a  generally  accepted 
fact  that  the  administration  of  dilute  hydrochloric  acid  in  the 
dosage  commonh-  emplo^^ed  is  entirely  ineffectual  as  an  active 


ALCOHOLIC  GASTRITIS.  779 

agent  in  gastric  digestion.  In  this  regard  it  has  been  stated 
(Sippy)  that  it  requires  approximately  100  drops  of  dilute 
hydrochloric  acid  to  aid  in  the  digestion  of  15  grams  of 
albumin.  Therefore,  with  a  patient  on  a  diet  calling  for  100 
grams  of  protein,  it  would  require  600  or  700  drops  of  the 
dilute  hydrochloric  acid.  This  amount  cannot  be  adminis- 
tered except  by  means  of  the  stomach-tube. 

In  antacid  gastritis,  where  the  administration  of  acids  is 
not  well  borne,  they  should  be  withdrawn  and  the  gastric 
state  kept  alkaline  with  bicarbonate  of  soda  or  other  antacids, 
the  diet  being  arranged  upon  a  plan  suitable  for  intestinal 
digestion,  which  sometimes  may  be  aided  by  the  use  of  taka- 
■diastase,  pancreatin  (preferably  pancreon),  or  inspissated  bile- 
salts  in  a  dosage  of  5  to  10  grains  (0.6  to  1.2  Gms.),  given" 
after  meals.  There  are  various  preparations,  such  as  oxyntin, 
acidol  tablets,  gastrinin,  and  similar  well-advertised  prepara- 
tions which  have  no  especial  advantage  over  the  official  dilute 
tincture  of  hydrochloric  acid,  besides  being  considerably  more 
expensive. 

ALCOHOLIC  GASTRITIS. 

This  type  of  gastric  catarrh,  if  of  long  standing,  usually 
is  accompanied  by  marked  subacidity  or  anacidity,  with  an 
overproduction  of  mucus,  and  where  cirrhotic  changes  in  the 
liver  have  occurred,  achylia  is  commonly  encountered.  Prop- 
erly treated,  a  symptomatic  cure  can  be  accomplished,  but  a 
real  or  anatomic  cure  will  depend  upon  the  amount  of  struc- 
tural damage  already  inflicted,  and  upon  the  reparative  power 
of  the  individual  mucous  membrane.  The  essentials  of  treat- 
ment consist  of  the  immediate  total  withdrawal  of  alcohol, 
the  use  of  chloral  and  bromides  administered  by  bowel  to 
allay  restlessness,  and  the  application  of  detoxication  methods 
by  flushing  the  intestines,  kidneys  and  skin.  To  this  end  one 
may  use  hot  applications  to  the  abdomen,  and  later  hot  packs 
or  vapor  baths,  the  free  use  of  some  good  spring-water  to  act 
as  a  diuretic,  and  the  use  of  small  doses  of  the  compound 
jalap  powder  to  aid  in  the  withdrawal  of  fluid  from  the  tis- 
sues. By  these  means  much  of  the  -alcoholic  bloat  can  be 
removed,  and  later  on  the  atonic  muscles  may  be  restored  by 
electrical  or  hydropathic  methods,  assisted  by  voluntary  exer- 


780  DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

cise.  It  is  needless  to  state  that  the  patient  must  be  a  "blue 
ribboner"  to  the  end  of  his  days,  if  anything  like  a  satisfac- 
tory result  is  to  be  secured.  During  the  first  part  of  the 
active  treatment  a  liquid  diet  should  be  maintained,  which 
later  may  be  increased  to  a  point  compatible  with  the  patient's 
gastric  chemistry. 

Where  the  stimulating  effect  of  alcohol  is  suddenly  with- 
drawn the  cardiac  symptoms  will  often  require  digitalis, 
which  may  be  given  alone  or  combined  with  capsicum,  the 
latter  being  extreme^  serviceable  in  alcoholic  gastritis.  The 
following  prescription  is  useful : 

B  Tinct.  capsici  fSj  (4  mils) . 

Tinct.  digitalis f3ij   (8  rmls). 

Tinct.  gentiani  comp...q.  s.   ad    fSiij  (100  mils). 
M.     S. :     Take  1  teaspoonful    (3.75  mils)    in  1   or  2 
ounces  (30  or  60  mils)  of  water  before  meals. 

An  ice-bag  should  be  kept  over  the  precordia,  and  the  use 
of  depressants  should  be  avoided.  To  allay  restlessness  in 
cases  verging  upon  delirium  tremens,  in  addition  to  the  use 
of  chloral  and  bromids,  Lockwood  speaks  well  of  the  effects 
of  paraldehyd,  given  two  or  three  times  a  day  in  teaspoonful 
(3.75  mils)  doses,  although  it  has  a  disagreeable  taste  and 
odor,  and  is  likely  to  upset  the  stomach. 

After  the  acute  symptoms  have  subsided  the  further  treat- 
ment does  not  difter  in  anywise  from  that  of  other  forms  of 
chronic  gastritis,  except  that  alcohol  must  be  completely 
interdicted. 

SYPHILIS    OF   THE    STOMACH. 

This  is  a  disease  of  the  stomach  caused  by  the  Treponejna 
pallidum  of  Schaudinn,  which  may  affect  the  mucosa  and  sub- 
mucosa  of  the  gastric  wall,  either  alone  or  in  combination.  It 
may  result  from  both  hereditary  and  acquired  syphilis,  but 
in  both  types  it  should  be  considered  a  tertiary  lesion.  AVhile 
it  represents  one  of  the  rarer  implantations  of  visceral  syph- 
ilis, it  may  yet  prove  to  be  far  more  common  than  we  were 
once  led  to  believe.  About  twenty-five  years  ago  Chiari^'^ 
reported  243  post-mortems  on  syphilitic  individuals,  and  found 
definite  syphilitic  involvement  of  the  stomach  in  but  two  in- 
stances, an  incidence  of  0.8  per  cent.     More  recently  Stolper 


SYPHILIS  OF  THE  STOMACH.  781 

has  autopsied  86  patients  who  have  died  of  syphilis,  and  has 
found  2  cases  showing-  definite  syphiHtic  invasion  of  the 
stomach.  Averaging  this  total  of  329  cases  with  four  in- 
stances of  gastric  syphilis,  the  frequency  of  this  disease,  from 
a  post-mortem  standpoint,  is  1.2  per  cent. 

It  is  to  be  presumed  that  this  estimate  will  prove  far  too 
low,  in  view  of  the  comparatively  large  number  of  cases  of 
gastric  syphilis  that  have  been  published  in  recent  years. 
For  instance,  William  Gerry  Morgan-^'^  reports  8  cases  occur- 
ring in  his  practice  in  the  past  twelve  years,  the  majority  of 
which  occurred  within  the  last  three  years,  which  were  diag- 
nosed partly  from  historic  and  symptomatic  evidence,  and 
partly  by  jr-ray,  serologic  and  operative  means.  None  of 
these  cases  came  to  autopsy.  It  is  manifestly  a  difficult  mat- 
ter accurately  to  determine  its  true  frequency.  Theoretically, 
we  might  insist  upon  the  demonstration  of  definite  pathologic 
lesions  of  syphilis,  preferably  showing  the  presence  of  the 
specific  spirocheta,  but  for  practical  purposes  we  may  rest 
content  in  the  accuracy  of  our  diagnosis  in  each  suspicious 
case  in  which  the  serologic  examinations  are  definitely  posi- 
tive, and  in  whom  antisyphilitic  therapy  results  not  only  in 
a  general  clinical  improvement,  but  in  a  cessation  of  gastric 
symptoms.  If  this  latter  criterion  is  accepted  the  frequency 
of  gastric  syphilis  will  be  considerably  increased.  We  must 
remember,  however,  that  syphilis,  visceral  or  otherwise,  and 
other  kinds  of  gastric  affections  may  occur  simultaneously  in 
the  same  patient,  and  each  be  independent  of  the  other;  or 
cases  in  whom  the  gastric  condition  may  be  functional  and 
not  organic,  but  secondary  to  syphilis,  as  notably  seen  in  the 
gastric  crises  associated  with  S3^philis  of  the  spinal  cord. 
Being  a  tertiary  lesion,  it  is  far  more  likely  to  become  mani- 
fest during  the  middle  decades  of  life,  may  affect  both  sexes, 
and,  as  stated  above,  may  occur  as  a  result  of  both  congenital 
and  acquired  infection. 

Pathologically,  the  disease  may  show  any  one  of  the  fol- 
lowing forms : 

1.  A  diffuse  gastritis,  affecting  the  glandularis  and  sub- 
mucosa. 

2.  Syphilitic  ulcers,  single  or  multiple,  frequently  assum- 


782  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

ing  serpiginous  forms,  and  having  ragged  overhanging  edges 
and  a  smooth  base. 

3.  A  diffuse  infiltration  of  the  gastric  wall,  which  his- 
tologically must  be  distinguished  from  linitis  plastica  (unless 
these  two  conditions  are  one  and  the  same,  as  many  clinicians 
believe),  from  a  diltuse  scirrhous  carcinoma,  and  from  a 
diffuse  infiltration  of  a  tuberculous  type. 

4.  Pyloric  stenosis. 

5.  Gumma,  which  may  or  ma^^  not  give  rise  to  a  palpable 
tumor. 

From  a  histologic  standpoint,  the  findings  are  practically 
those  of  tertiary  syphilis  occurring  elsewhere.  There  may  be 
diftuse  round-cell  infiltration,  connective-tissue  infiltration, 
frequently  a  general  arrangement  in  the  form  of  tubercles, 
and  often,  but  not  invariably,  furnished  with  giant  cells  wath 
the  nuclei  usualty  situated  eccentrically.  There  may  be  areas 
of  coagulation  necrosis  in  the  centers  of  such  tubercles,  but 
they  show  an  indifferent  tendency  to  the  coalescence  seen  in 
tuberculosis.  There  may  be  endotheloid  as  well  as  lymphoid 
and  connectiA'e-tissue  hyperplasia.  One  of  the  most  constant 
features  is  the  obliterating  endarteritis,  which  in  part  may 
account  for  the  caseation  necrosis  due  to  lack  of  vascularity, 
and  which,  too,  may  furnish  a  second  etiologic  factor  in  the 
production  of  the  ulcer  form  in  gastric  syphilis.  In  some 
instances  the  diagnosis  can  be  made  beyond  dispute  by  the 
demonstration  of  the  Treponema  pallidum  in  tissue  differ- 
entially stained. 

A  clinical  classification  can  be  readily  built  up,  and  made 
to  correspond  to  the  pathologic  form. 

The  symptoms  may  vary  as  widely  as  the  pathologic  lesion, 
and  in  many  cases  there  are  no  symptoms  which  of  them- 
selves can  be  considered  pathognomonic.  Quite  commonly 
we  see  the  symptom-complex  of  an  organic  disease  of  the 
stomach  implicating  both  the  motor  and  secretory-  mechanism. 
Aside  from  the  comparatively  few  instances  of  motor  obstruc- 
tion due  to  syphilitic  pyloric  stenosis,  the  motor  defect  is 
much  more  commonly  due  to  an  extreme  degree  of  atony 
associated  with  ectasia.  The  secretory  defect  is  usually  ac- 
companied by  the  symptoms  of  a  severe  atrophic  or  sclerosing 
gastritis.     Pyrosis  is  common,  and  is  of  the  type  seen  in  the 


SYPHILIS  OF  THE  STOMACH.  783 

achylic  states ;  sour  eructations,  together  with  the  sense  of 
an  epigastric  lump,  weight,  or  pressure,  sometimes  associated 
with  bloating,  are  the  symptoms  common  to  atony,  together 
with  the  fermentations  seen  in  ectasia. 

In  the  ulcer  form  one  of  the  early  symptoms  may  l)e  a 
profuse  hematemesis,  which  is  more  likely  to  be  recurrent 
than  is  common  in  simple  gastric  ulcer.  In  this  form  there 
is  frequently  pain,  which  commonly  occurs  late  in  the  day, 
bears  a  less  striking  time  relation  to  meals  than  the  pain  of 
simple  ulcer,  and  is  not  so  easily  amenable  to  further  food- 
taking,  or  to  non-specific  chemical  therapy.  There  may  be 
constitutional  symptoms  common  to  many  diseases,  such  as 
anorexia,  loss  of  weight,  weakness  and  emaciation.  Exces- 
sive thirst  is  not  uncommon.  In  ordinary  cases  the  intestinal 
functions  are  properly  performed;  when  these  functions  are 
deranged,  constipation  is  a  frequent  consequence. 

The  gastric  analyses  much  more  commonly  show  a  marked 
subacidity  or  anacidity  with  a  greatly  diminished  or  absent 
enzyme  activity,  which  is  what  one  might  expect  to  find  asso- 
ciated with  the  pathologic  defect  of  an  atrophic  gastritis.  On 
the  other  hand,  a  few  cases  have  been  reported  in  which  the 
hydrochloric  acid  content  and  peptic  activity  are  normal,  or 
even  increased.  An  increase  of  endogenous  mucus  is  gener- 
ally the  rule.  Occult  bleeding  is  frequently  encountered,  both 
in  the  gastric  filtrate  and  in  the  feces.  The  blood  examina- 
tions, when  diagnostically  helpful,  usually  show  a  chloroane- 
mia,  and  a  moderate  leucopenia,  with  a  relative  increase  of 
lymphocytes,  and  an  absolute  increase  of  eosinophiles.  The 
serologic  examinations  generally  yield  a  definitely  positive 
Wassermann  reaction,  and  the  test  is  especially  reliable  when 
performed  by  the  centrifuge  method, ^^  and  when  checked  by 
the  Hecht-Weinberg-Wassermann  reaction  as  modified  by 
Gradwohl.4o 

In  cases  exhibiting  active  symptoms  the  .r-ray  examina- 
tion usually  demonstrates  some  definite  defect  in  the  gastric 
outline. 

The  physical  findings  may  give  evidence  of  a  severe  consti- 
tutional infection,  featured  by  anemia  and  cachexia,  although 
these  may  frequently  be  lacking.  Evidence  of  generalized 
syphilis    may    be   4isclosed    in   the    teeth,    tongue,    gums    or 


784  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

phar>^nx ;  in  the  finding  of  a  generalized  adenopathy ;  in  a 
manifest  syphilitic  eruption;  in  visible  scars  on  the  genitalia, 
or  the  scars  from  syphilitic  ulcers  on  the  extremities.  Ab- 
dominal examination  as  restricted  to  the  stomach  itself  may 
give  no  diagnostic  evidence,  but  one  frequently  can  demon- 
strate an  atony,  dilatation,  or  both  in  the  widened  area  of  gas- 
tric tympany,  and  the  presence  of  secussion  splashes.  In 
some  cases  one  may  imagine  the  palpatory  sensation  of  a 
thickened  anterior  gastric  wall.  There  may  be  diffuse  epigas- 
tric tenderness,  but  even  in  the  definite  ulcer  cases  painful 
pressure  points  are  often  lacking.  In  some  cases  there  may 
be  palpator}^  evidence  of  a  gastric  tumor,  which  in  emaciated 
subjects  may  be  visible.  This  is  seen,  of  course,  only  in  the 
gummatous  forms,  and  in  syphilitic  hypertrophic  stenosis. 
When  a  palpatory  tumor  is  evident  it  ma}-  readily  be  mis- 
taken for  carcinoma,  but  under  observ^ation  usually  remains 
quiescent  as  to  size  or  disappears  under  specific  treatment. 
Further  abdominal  examination  may  disclose  cA^idence  of  a 
syphilitic  hepatitis  or  splenitis. 

As  in  some  other  gastric  conditions  the  diagnosis  may  have 
to  be  made  by  a  process  of  exclusion.  Particularly  is  this 
true  of  those  individuals  who  give  evidence  of  both  a  syph- 
ilitic infection  and  a  gastric  affection,  each  independent  of  the 
other.  In  those  cases  in  whom  a  positive  history  of  a  con- 
genital or  acquired  syphilis  can  be  obtained,  the  diagnosis  can 
be  made  a  clinically  sound  one  if  the  serologic  examinations 
are  positive,  and  there  is  a  cessation  of  gastric  symptoms,  and 
a  return  to  normal  of  the  radiographic  gastric  contour  after 
the  exhibition  of  antiluetic  therapy.  Further  than  this,  the 
writer  cannot  do  better  than  quote  some  of  the  observations 
as  published  in  ^Morgan's  paper: 

"1.  That  the  failure  to  glean  from  the  individual  anything 
suspicious  of  a  syphilitic  taint,  or  an  abortion,  or  failure  to 
have  children,  or  a  negative  Wassermann,  does  not  prove  that 
syphilis  does,  or  does  not,  exist  in  that  patient. 

"2.  A  diseased  condition  of  the  stomach  marked  by  a  long 
duration  with  changeable  symptoms,  and  which  do  not  corre- 
spond to  one  or  other  of  the  well-recognized  diseases  of  that 
organ,  and  which  resist  the  accepted  methods  of  treatment, 
should  arouse  suspicion  of  lues. 


SYPHILIS  OF  THE  STOMACH.  785 

"3.  Tumors  involving  the  pylorus  which  do  not  cause 
stenosis  are  more  often  syphiHtic  than  carcinomatous. 

"4.  Achylia  or  a  low  acidity,  as  occurred  in  all  our  cases, 
is  usual  in  gastric  syphilis ;  and  where  there  is  achylia  with 
symptoms  of  ulcer,  one  is  likely  to  have  an  ulcerating  gumma 
or  a  superficial  ulcer  on  a  syphilitic  infiltration  base  in  the 
gastric  wall. 

"5.  Diffuse  syphilitic  infiltration  is  usually  easily  detected 
by  the  palpating  fingers,  because  it  produces  some  enlarge- 
ment of  the  stomach  which,  as  happened  in  some  of  our  cases, 
may  not  be  readily  recognized  at  operation.  This  may  be 
true  even  when  the  infiltrating  mass  is  to  be  detected  by  the 
rontgen  ray. 

"6.  A  tumor  which  does  not  change  its  size  and  shape  over 
long  periods  of  observation  may  be  syphilitic,  or  a  tumor 
which  disappears  under  antisyphilitic  treatment  may  be  pre- 
sumed to  be  a  gumma." 

The  prognosis  is  no  more  grave  than  is  that  of  visceral 
syphilis  elsewhere,  and  is  usually  good  if  the  disease  is  prop- 
erly diagnosed,  and  specific  treatment  is  energetically  carried 
out. 

The  treatment  of  gastric  syphilis  is  practically  the  same  as 
is  indicated  in  any  late  secondary  or  tertiary  lesion  of  syphilis, 
save  those  of  the  spinal  or  central  nervous  system. 

The  first  essential  is  that  the  specific  therapy  should  be 
thoroug'hly  and  energetically  carried  out,  and  the  second 
essential  is,  that  it  should  be  kept  within  the  physiologic  tol- 
erance of  the  individual  patient.  Since  the  introduction  of 
our  newer  methods  of  treatment  sufficient  time  has  not  elapsed 
to  warrant  the  promise  of  a  cure  in  visceral  syphilis.  Follow- 
ing the  introduction  of  salvarsan  and  other  forms  of  intra- 
venous and  intramuscular  medication  in  many  cases  relapses 
have  been  frequently  noted.  It  is  yet  to  be  proved  whether 
long-sustained  treatment  with  appropriate  interruption  may 
finally  eventuate  in  a  real  cure.  Nevertheless,  we  can  be 
pretty  well  assured  of  promising  our  patients  a  symptomatic 
arrest  of  their  disease. 

As  to  the  method  of  therapeutic  procedure,  this  often  be- 
comes a  matter  of  individual  preference,  as  guided  by  per- 
sonal experience.     If  no  syphilitic  treatment  has  ever  been 


786  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

given  the  patient,  a  more  intensive  and  energetic  form  should 
be  adopted.  In  the  writer's  opinion  a  good  deal  depends  upon 
the  strength  of  the  serologic  test.  This  means  that  every 
Wassermann  that  is  returned  100  per  cent,  positive,  or  four 
plus,'*!  should  be  quantitatively  estimated,  inasmuch  as  it 
forms  such  an  important  check  on  the  eiTectiveness  of  our 
treatment.  In  the  writer's  experience  in  one  case  of  gastric 
syphilis,  with  a  palpable  gastric  tumor,  presumably  gumma, 
the  AVassermann  reaction  was  506  per  cent,  positive  (slightly 
over  twenty  plus),  and  with  specific  treatment  was  reduced 
to  35  per  cent,  positive  (slightly  over  one  plus),  at  which  time 
the  patient  was  operated  upon  for  the  relief  of  a  complicating 
duodenal  ulcer  from  which  he  finally  succumbed. 

In  some  cases  treponemas  are  locked  up  in  the  heart  of  a 
pathologic  syphilitic  lesion,  and  on  account  of  the  devascu- 
larity  attendant  upon  the  endarteritis,  the  syphilitic  antibodies 
may  not  have  access  to  the  circulating  blood-stream.  In  such 
cases  the  Wassermann  reaction  may  be  negative,  until  a  pro- 
vocative intravenous  injection  of  salvarsan  has  been  given, 
or  may  be  weakly  positive  to  begin  with,  with  a  generally 
increasing  positivity  under  treatment,  until  a  definite  point  of 
pathologic  cure  has  been  reached,  when  the  serologic  reaction 
progressively  diminishes  in  intensity. 

In  all  cases  of  visceral  syphilis  the  three  forms  of  specific 
chemical  therapy,  either  in  periodic  courses  alone  or  in  com- 
bination with  one  another,  will  be  indicated :  namely,  potas- 
sium iodid,  the  various  forms  of  mercury,  and  the  various 
forms  of  arsenic.  Where  there  is  clinical  evidence  of  a  pal- 
pable gastric  tumor,  either  a  gumma  or  a  hypertrophic  steno- 
sis, the  action  of  potassium  iodid,  supplemented  by  or  asso- 
ciated" with  the  use  of  mercury,  often  results  in  a  miraculous 
disappearance  of  the  objective  findings.  -  These  two  remedies 
best  serve  to  break  down  the  connective-tissue  barrier  sur- 
rounding the  gummatous  lesions,  and  so  liberate  the  spiro- 
chetse,  and  give  them  or  their  antibodies  access  to  the  blood- 
stream, w^here  they  can  be  more  effectively  attacked  by  the 
intravenous  injection  of  neosalvarsan,  or,  perferably,  salvar- 
san. Potassium  iodid  should  be  given  in  the  form  of  a 
saturated  solution,  in  a  dosage  beginning  with  10  or  15  drops 
(0.625  or  0.9375  mil)   three  times  a  day,  preferably  taken  in 


SYPHILIS  OF  THE  STOMACH.  787 

milk,  before  meals,  and  increasing-  the  amount  given  1  drop 
each  dose  until  the  physiologic  tolerance  of  the  patient  has 
been  reached,  after  which  the  dosage  may  be  dropped  to  one- 
half  or  three-quarters  this  amount,  and  continued  for  inter- 
rupted periods  of  two  weeks  each  for  the  first  year,  and  grad- 
ually decreased,  if  warranted,  during  the  second  and  third 
years,  with  short  exhibitions  thereafter  as  long  as  may  be 
required.  Together  with  this  there  should  be  given  mercury, 
far  preferably  by  deep  intramuscular  injection  in  the  buttocks, 
in  the  form  of  either  the  soluble  or  insoluble  salts,  preferably 
the  former.  Such  injections  should  be  given  daily  in  courses 
of  from  six  to  twelve,  and  then  interrupted,  to  be  resumed  in 
a  like  period,  and  then  to  be  alternated  with  intramuscular 
injections  of  the  cacodylate  of  soda,  beginning  with  1  grain 
(0.06  Gm.),  and  increasing  to  3  grains  (0.2  Gm.).  This  is 
the  method  the  writer  prefers  in  such  patients  as  show  a  low 
positive  serologic  reaction  until  the  reaction  becomes  more 
strongly  positive,  when  the  use  of  intravenous  injections  of 
the  arsenical  group,  salvarsan,  neosalvarsan,  arsenobenzol  is 
to  be  begun,  and  given  at  intervals  of  a  week  or  ten  days  until 
a  course  of  three  or  four  such  injections  have  been  made. 

The  objection  to  the  use  of  potassium  iodid,  however  use- 
ful it  may  be  in  the  solution  of  gumma,  lies  in  the  fact  of  its 
disordering  effect  upon  the  gastric  digestion.  Furthermore, 
its  use  should  be  avoided,  or  most  cautiously  proceeded  with, 
in  tuberculous  patients,  especially  in  the  quiescent,  fibroid 
forms  of  phthisis,  on  account  of  the  danger  of  lighting  up  this 
infection. 

Likewise,  the  use  of  the  preparations  of  mercury,  either 
the  protiodid  or  the  biniodid  of  mercury,  or  the  pill  of 
mixed  treatment,  when  administered  by  mouth  should  be 
deprecated,  inasmuch  as  they  not  only  upset  the  digestion, 
but  the  amount  of  absorption  cannot  be  accurately  controlled. 
For  oral  administration  the  writer  prefers  the  use  of  calomel, 
in  combination  with  bismuth  subcarbonate  or  powdered  chalk 
to  counteract  diarrhea.  The  advantage  of  intramuscular  in- 
jections of  mercury  is  therefore  evident.  If  it  is  to  be  admin- 
istered otherwise,  the  use  of  inunctions  is  the  method  next 
of  choice.  Calomel  ointment  is  proving  an  agreeable  and  ef- 
ficient substitute  for  the  objectionably  dirty  "blue  ointment," 


788  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

It  is  needless  to  state  that  before  beginning  such  a  vigorous 
use  of  mercury,  the  mouth  and  teeth  should  be  put  in  a  state 
of  oral  cleanliness,  and  so  maintained;  should  there  be  evi- 
dence of  ptyalism  or  gingivitis,  this  drug  should  be  discon- 
tinued for  a  short  period,  or  its  dosage  materially  reduced. 

In  cases  in  which  the  Wassermann  reaction  is  relatively 
high,  thus  indicating  that  the  Treponema  pallidum  or  its 
specific  products  have  access  to  the  peripheral  circulation,  the 
use  of  intravenous  injections  of  the  various  forms  of  arsenic 
should  be  begun  at  once,  supplemented  certainly  by  the 
use  of  mercury,  and  with  less  certainty  potassium  iodid. 
Salvarsan  appears  to  be  a  little  more  effective  than  the  neo- 
salvarsan,  but  its  comparatively  greater  difficulty  of  admin- 
istration makes  it  less  commonly  used.  If  there  are  no 
contraindications  to  its  use,  and  if  it  is  well  tolerated,  an 
injection  should  be  given  every  week  or  ten  days  until  four 
or  five  have  been  made,  and  then  given  once  a  month  for  the 
first  year,  once  every  second  month  through  the  second  year, 
and  twice  a  year  thereafter  as  long  as  need  be.  During  this 
time  injections  of  mercury  may  be  given  at  stated  intervals, 
or  a  short  course  of  intramuscular  injections  of  the  cacodylate 
of  soda,  and  the  periodic  exhibition  of  potassium  iodid  in 
small  doses,  30  to  60  drops  (1.9  to  3.75  mils),  daily. 

The  sug'gestions  as  to  treatment  outlined  above  represent 
the  method  that  has  proven  useful  in  the  writer's  experience 
in  the  treatment  of  visceral  syphilis.  It  should  be  thoroughly 
understood  that  there  can  be  no  syphilijtic  treatment  given  by 
rule  of  thumb,  but  that  a  definite  plan  should  be  adopted,  and 
modified  according  to  the  requirements  in  the  individual  case. 
As  stated  above,  the  two  important  essentials  are  that  it 
should  be  thoroughly  adequate,  and  kept  within  the  limits  of 
tolerance  of  the  patient,  and  finally  that  it  should  be  main- 
tained until  the  Wassermann  reaction  has  been  consecutively 
negative  for  a  period  of  three  years,  whether  this  takes  five 
years  or  the  remainder  of  the  patient's  lifetime  to  accomplish. 
Only  by  this  means  can  we  be  content  with  the  assurance 
that  the  specific  condition  has  been  permanently  arrested  or 
cured. 

Otherwise  the  treatment  of  gastric  syphilis  is  purely 
symptomatic.      The    dietetic,    mechanical,    balneological,    and 


TUBERCULOSIS  OF  THE  STOMy\CH.  789 

medicinal  treatment  is  essentially  the  same  as  that  outlined 
for  the  management  of  chronic  gastritis,  as  discussed  on  page 
763  ct  seq. 

For  the  treatment  of  the  gastric  atony  and  dilatation  the 
use  of  intragastric  and  extragastric  electricity  and  vibratory 
massage  is  indicated,  and  these  methods  are  discussed  in 
detail  elsewhere.     (See  p.  773.) 

TUBERCULOSIS    OF   THE    STOMACH. 

Tuberculosis  of  the  stomach  is  a  rare  disease.  Available 
statistics'*^  gjve  its  frequency  as  occurring  in  0.5  per  cent,  of 
all  autopsies,  and  in  2.3  per  cent,  of  autopsies  made  upon 
those  cases  dying  of  tuberculosis.  If  one  is  unable  by  gross 
and  microscopic  pathology  satisfactorily  to  demonstrate  the 
presence  of  tuberculous  lesions  in  a  given  case,  it  is  therefore 
quite  impossible  to  hazard  more  than  a  mere  guess  that  this 
disease  has  been  present  during  life.  The  commonest  form 
of  gastric  tuberculosis  is  an  ulcer  formation  which  is  com- 
monly solitary,  but  may  be  multiple.  Such  multiple  ulcers 
are  much  more  likely  to  occur  in  a  generalized  infection  of 
the  miliary  type.  The  next  most  common  form  of  tuberculous 
lesion  is  pyloric  stenosis,  in  which  overgrowths  of  tuberculous 
connective  tissue  have  become  localized  in  the  walls  of  the 
stomach  at  the  pyloric  region,  or  in  which  a  tuberculous 
pyloric  ulcer  has  undergone  cicatrization,  with  a  narrowing  of 
the  pyloric  lumen.  In  this  connection  we  must  bear  in  mind 
that  gastric  or  duodenal  ulcers,  or  benign  hypertrophic  ste- 
nosis, may,  and  more  frequently  do,  occur  as  independent 
conditions  in  patients  in  whom  extragastric  tuberculosis  can 
be  demonstrated,  and  that  unless  a  definite  gastric  pathology 
can  be  furnished  such  cases  should  not  be  classified  under  this 
category. 

Other  less  common  forms  that  have  been  described  are 
the  occasional  solitary  tubercles  found  in  the  stomach-walls, 
and  tuberculous  tumors  closely  simulating  carcinoma,  which 
are  more  apt  to  aiject  the  pyloric  region  and  cause  obstruction. 

In  pulmonary  tuberculosis,  especially,  and  quite  commonlv 
in  renal  and  intestinal  tuberculosis,  functional  disturbances  of 
the  stomach  become  evident  in  most  cases  rather  early.    These 


790  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

disturbances  implicate  both  secretion  and  motility.  In  the 
order  of  their  frequency  this  secretory  disturbance  is  that  of 
a  subaeidity  with  delayed  digestion,  next  most  commonly  an 
anacidity,  and  but  comparatively  rarely  a  hyperchlorhydria. 
These  clinical  observations,  while  well  known,  have  never 
been  so  clearly  demonstrated  as  in  the  recent  fractional  gas- 
tric studies  of  H.  K.  Mohler  and  E.  H.  Funk,43  which  were 
carried  out  on  47  tuberculous  patients. 

While  the  functional  suppression  of  gastric  secretion  is 
undoubtedly  more  common,  many  of  such  charted  findings 
may  be  due  to  an  organic  change,  non-tuberculous  gastritis, 
which  may  proceed  to  the  atrophic  form.  The  commonest 
motor  disturbance  is  that  of  atony,  which  ma}^  occur  in  an 
aggravated  form,  although  it  is  generally  of  mild  degree,  and 
in  consequence  a  secondary  ectasia  may  develop.  Where 
visceroptosis  is  a  complicating  feature  the  functional  gastric 
disturbances  are  much  more  pronounced,  and  particularly  as 
it  affects  motility. 

While  the  etiologic  factor  of  gastric  tuberculosis  (Koch's 
bacillus)  is  definitely  known,  its  commonest  portal  of  entry 
is  still  a  matter  of  dispute.  Theoretically,  we  may  assume 
that  the  readiest  route  would  occur  by  direct  implantation  of 
the  tubercle  bacillus  at  a  receptive  point  of  the  gastric  mucosa 
from  the  swallowing  of  tubercular  sputum,  or  from  the  inges- 
tion of  food  infected  with  tuberculous  dust.  This  theoretic 
belief,  however,  is  oft'set  by  our  knowledge  of  the  somewhat 
bactericidal  action  of  the  gastric  juice  plus  the  relatively  fas- 
ter emptying  power  of  the  stomach  as  compared  with  that  of 
the  intestinal  tract,  which  accounts  for  the  greater  frequency  of 
intestinal  tuberculous  ulceration.  Again,  this  holds  true  from 
the  fact  that  the  stomach  is  furnished  with  much  fewer  lym- 
phoid follicles  than  those  of  the  intestines  (Barchasch),,  in 
view  of  which  infection  by  way  of  the  lymph-channels  must 
be  comparativel}^  infrequent,  although  it  would  seem  to  have 
occurred  in  such  a  manner  in  various  reported  cases.  As  we 
are  now  aware  that  subaeidity  is  the  commonest  secretory 
disturbance,  it  is  evident  that  the  bactericidal  efliciency  of  the 
gastric  juice  would  be  lessened  in  proportion  to  its  amount  and 
its  concentration,  and  as  the  chief  gastric  motor  error  asso- 
ciated with  pulmonary  tuberculosis  is  that  of  atony,  a  delay 


TUBERCULOSIS  OF  THE  STOMACH.  791 

of  gastric  emptying  power  also  is  to  be  expected.  Therefore, 
these  two  factors  may  counteract,  to  a  certain  extent,  what 
has  been  stated  above,  and  may  permit  more  ready  secondary 
infection  of  the  stomach  from  swallowed  sputum  or  food  con- 
taminated by  the  infecting  germ. 

The  third  portal  of  entry  is  by  way  of  the  blood,  and  the 
writer  is  inclined  to  agree  with  Arloing  that  this  is  the  more 
common  method,  inasmuch  as  the  diffuse  miliary  forms  of 
gastric  tuberculosis  are  more  common  than  the  chronic  local- 
ized ulcers.  Furthermore,  Arloing  has  been  able  to  produce 
tuberculous  gastric  and  duodenal  ulcers  by  injecting  tubercle 
bacilli  directly  into  the  blood-stream. 

The  pathology  of  tuberculosis  of  the  stomach  is  quite 
similar  to  that  of  tuberculosis  elsewhere.  Tuberculous  gas- 
tric ulcers  usually  present  a  much  more  worm-eaten,  over- 
hanging edge  than  is  seen  in  simple  ulcer,  and  the  floor  of  the 
ulcer  may  be  necrotic,  and,  in  certain  cases,  may  be  seen  to  be 
studded  with  miliary  tubercles. 

The  symptomatology  of  gastric  tuberculosis  is  by  no  means 
characteristic,  and  during  life  its  presence  can  only  be  sus- 
pected. If  there  is  a  tuberculous  ulcer  the  symptoms  are 
much  the  same  as  those  occurring  in  simple  gastric  ulcer, 
although  commonly  the  pain  is  continuous,  and  may  occur  at 
an  earlier  time  relation  to  food-taking.  Not  infrequently 
acute  hematemesis  or  perforation  furnishes  the  first  proof  of 
its  presence.  By  far  the  commonest  symptoms  are  those  of 
insufficient  secretory  power  with  delayed  motility,  but  it  is 
well-nigh  impossible  to  distinguish  between  those  symptoms 
occurring  as  a  result  of  organic  disease  and  those  functional 
disturbances  secondary  to  extragastric  tuberculosis. 

As  might  be  inferred  from  the  brief  review  of  symptoms, 
an  accurate  diagnosis  during  life  can  rarely  be  made.  Direct 
diagnostic  findings,  such  as  the  demonstration  of  tubercle 
bacilli  in  the  gastric  contents,  is  of  but  relative  importance, 
inasmuch  as  it  occurs  so  frequently  in  the  swallowing  of 
tuberculous  sputum,  and  their  presence  by  no  means  indicates 
that  the  stomach  is  directly  infected.  Similarly  such  diagnostic 
tests  as  the  Calmette  and  von  Pirquet  reactions  are  not  only 
unreliable,  but  when  positive  merely  indicate  the  presence  of  a 
tuberculous  focus,  past  or  present,  somewhere  in  the  body. 


792  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

In  certain  cases  of  gastric  ulcer  in  patients  in  whom  a 
definite  improvement  cannot  be  secured  by  a  rigid  medical 
regime  for  simple  ulcer,  or  by  the  use  of  antiluetic  measures, 
and  in  whom  a  tuberculous  type  of  ulcer  is  suspected,  this 
supposition  may  be  strengthened  if  improvement  follows  the 
therapeutic  exhibition  of  injections  of  tuberculin. 

The  prognosis  of  gastric  tuberculosis,  though  grave  enough, 
is  no  more  so  than  that  of  generalized  or  local  visceral  tuber- 
culosis elsewhere,  except  in  the  event  of  complications,  such 
as  an  acute  gastric  hemorrhage  or  perforation. 

The  treatment  is  that  of  tuberculosis  in  general.  Fresh 
air,  a  change  of  climate,  if  need  be,  rest,  and  a  strict  obser- 
vance of  the  general  principles  of  treatment  of  simple  gastric 
ulcer,  as  already  outlined.  (See  p.  684.)  If  there  be  an  asso- 
ciated visceroptosis,  the  proper  elevation  of  the  foot  of  the 
bed  should  be  carried  out  during  the  entire  bed-rest  treatment, 
and  the  use  of  a  Rose  adhesive  plaster  belt  may  be  substituted 
for  the  Priesnitz  bandage  after  the  second  week  of  treatment. 
Every  effort  should  be  made  to  build  up  weight  by  conserv- 
ing the  energy  output,  and  by  the  use  of  high  caloric  diets,  to 
the  end  that  the  resistance  of  the  natural  body  defences  be 
strengthened. 

Treatment,  preferably,  should  be  carried  on  out-of-doors, 
on  a  sleeping  porch,  or  on  the  bridge  or  grounds  of  a  well- 
conducted  hospital  or  sanatorium,  and  to  be  at  all  worth  while 
should  be  carried  on  energetically  for  months. 

The  writer  has  been  much  impressed  by  the  almost  mar- 
velous improvement  that  has  taken  place  in  certain  cases  of 
miliary  intestinal  tuberculosis,  in  which  the  stomach  may,  or 
may  not,  have  been  similarly  infected,  and  in  which  an  explor- 
atory operation  disclosed  dense  masses  of  adhesions  with 
miliary  tubercles  of  both  visceral  and  parietal  peritoneum, 
with  or  without  free  fluid  in  the  abdominal  cavity,  and  the 
intestines  matted  together  by  dense  adhesions.  Some  such 
cases,  though  clearly  inoperable,  have  been  miraculously  im- 
proved, apparently  merely  by  opening  the  abdominal  cavity 
and  exposing  it  for  a  fev/  minutes  to  the  light  and  air  of  the 
operating  room,  draining  out  the  free  fluid,  and  replacing  it 
by  several  quarts  of  normal  salt  solution,  after  which  the 
abdomen  is  closed.    The  after-treatment  has  consisted  of  sev- 


TUBERCULOSIS  OF  THE  STOMACH.  793 

eral  weeks  of  bed-rest,  prefera1)ly  in  the  open  air,  with  plenty 
of  sunshine  and  an  abundance  of  nourishing  food,  and  the  use 
of  mineral  oils  as  an  intestinal  lubricant. 

The  writer  has  watched  several  such  cases  gain  thirty  to 
forty  pounds  in  weight  with  a  complete  cessation  of  the  gas- 
trointestinal symptoms,  notably  an  absence  of  gas-pains,  and 
with  no  recurrence  of  the  irregularly  shaped,  evanescent, 
gaseous  tumors,  the  result  of  the  abdominal  adhesions,  so 
noticeable  before  operation.  While  it  is,  of  course,  almost 
inconceivable  that  there  should  have  occurred  any  real  cure 
from  an  anatomico-pathologic  standpoint,  nevertheless,  on 
re-examination  of  these  patients,  a  year  or  two  later,  one 
would  never  suspect  that  the  abdomen  contained  the  state  of 
affairs  that  was  noted  at  the  operating  table  months  before. 

As  a  rule,  no  further  radical  surgery  should  be  attempted 
in  such  cases,  with  the  exception  of  such  localized  tuberculous 
ulcers  of  the  stomach  as  are  freely  accessible,  and  not  bound 
down  by  adhesions,  therefore  admitting  of  radical  resection. 
Even  then  it  is  a  surgical  question,  still  unsettled,  whether, 
the  risk  of  disseminating  a  somewhat  localized  process  may 
not  be  too  great.  The  surgery  that  concerns  cicatricial  or 
hypertrophic  stenoses  of  the  pylorus  becomes  a  matter  of 
judgment  whether  a  gastrojejunostomy  should  or  should  not 
be  performed  to  secure  better  drainage.  This  will  depend 
upon  the  amount  of  pyloric  obstruction. 

As  to  any  specific  medical  therapy,  there  is  none  that  can 
be  generally  applied  with  any  great  hope  of  success.  The 
foundation  of  all  treatment  should  be  the  appliance  of  the  four 
fundamental  principles  of  the  treatment  of  tuberculosis  in  gen- 
eral :  bodily  and  mental  rest,  fresh  air  and  sunshine,  abundant 
feeding,  and  the  use  of  such  expectant  measures  as  may  be 
indicated. 

As  regards  abundant  feeding,  the  writer  is  not  in  sympathy 
with  the  too  prevalent  custom  of  believing  that  this  should 
consist  of  the  three  usual  daily  meals,  with  all  the  milk  and 
eggs  that  the  patient  can  succeed  in  eating,  in  addition.  One 
must  bear  in  mind  that  there  are  usually  present  the  motor 
defects  of  atony,  with  secondary  gastrectasia,  and  the  cus- 
tomary plan  of  "forced  feeding"  usually  serves  to  aggravate 
this  condition.     In  addition,  many  of  these  patients  show  an 


794  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

intolerance  to  a  diet  too  rich  in  fat.  The  liquids  should  be 
restricted  as  in  the  treatment  of  atony  and  gastroptosia.  The 
writer  has  found  the  following  dietary  useful  in  the  manage- 
ment of  this  class  of  patients,  although  it  has  to  be  modified 
in  individual  cases. 

Breakfast.  A  cooked  cereal^  such  as  farina,  wheatena, 
cream  of  wheat  or  hominy,  may  be  eaten  with  cream  and 
sugar.  Oatmeal  may  be  allowed  if  very  thoroughly  cooked. 
An  occasional  lamb-chop  or  slice  of  breakfast  bacon.  Two 
soft-boiled  or  poached  eggs.  The  soft  parts  of  bread,  crackers, 
or  freshly  made  toast,  may  be  eaten  with  butter.  Milk,  malted 
milk,  or  cocoa  may  be  taken.  It  is  better  to  avoid  both  tea 
and  coffee. 

10  to  11  A.M.  The  choice  of  cream  and  rice-water  formula, 
or  malted  milk.  Koumiss,  kefir,  buttermilk,  or  equal  parts  of 
milk  and  cream,  junket,  or  cup-custard.  One  or  two  raw 
eggs  may  be  substituted,  or  added  to  any  of  the  foregoing. 
Crackers  and  butter. 

Luncheon  or  Dinner.  Chicken  or  fish  in  any  form  but  fried, 
broiled  squab,  or  the  breast  of  guinea-hen.  Broiled  or  boiled 
beef  and  lamb,  to  be  run  through  a  grinder  when  cooked. 
Milk  toast.  Oysters  in  any  form  but  fried.  Potatoes  in  any 
form  but  fried,  preferably  baked  or  mashed.  Peas,  lima  beans, 
spinach,  squash  (to  be  put  through  a  colander  and  pureed 
with  cream),  boiled  rice,  tender  string-beans,  buttered  beets, 
creamed  carrots,  or  the  tender  ends  of  asparagus  or  cauli- 
flower, spaghetti  or  macaroni.  A  salad  with  plain  lettuce  and 
French  dressing  (with  the  amount  of  vinegar  reduced)  may 
be  permissible  every  second  day,  if  desired.  Bread  and  but- 
ter. Choice  of  junket,  cup-custard,  blanc  mange,  tapioca,  rice, 
cornstarch,  or  bread-puddings,  floating  island,  and  vanilla  ice- 
cream, if  held  in  the  mouth  until  warmed  to  body  temperature. 

4  to  5  P.M.    The  same  choice  as-10  a.m. 

Supper  or  Dinner.  Thick  soups,  such  as  rice,  sago,  barley, 
farina,  potato,  or  asparagus ;  creamed  purees  of  beans,  peas 
or  lentils,  which  are  to  be  run  through  a  colander.  No  soups 
made  from  meat  or  meat-stocks  are  allowed.  One  or  two 
soft-boiled  or  poached  eggs.  Bread  and  butter.  Milk  or 
cocoa,  and  the  choice  of  any  of  the  above  desserts,  except  ice- 
cream. 


TUBERCULOSIS  OF  THE  STOMACH.  795 

Before  retiring  the  choice  of  the  foods  allowed  at  4  p.m. 
Avoid.     Fried,  greasy  foods;  pies,  cakes,  candy,  hot  cakes, 
mustard,  pepper,  vinegar,  pickles,  onions,  coarse  breads,  and 
all  fruits. 

The  writer  recommends  the  following  prescription,  which 
was  a  favorite  of  the  late  John  H.  Musser,  as  a  symptomatic 
remedy  for  the  relief  of  the  symptoms  of  epigastric  weight, 
pressure,  and  fullness,  with  sour  or  gaseous  eructations, 
symptoms  common  to  gastric  atony  and  ectasia  with  fermen- 
tation : 

IJ  Creosoti gr.  ss  to  j 

(0.03  to  0.06  Gm.). 

Spts.    chloroformi    Tn,iiss  (0.14  mils). 

Spts.  ammonise  aroniatici rrtv  (0.3  mils). 

Sodii  bicarbonatis   gr.  v  (0.3  Gm.). 

Liq.  sodcC  et  menthse  (N.F.) 

q.  s %]    (30  mils) , 

M.  S. :  One  teaspoonful  (3.75  mils),  to  be  taken 
in  a  little  water  one-half  to  one  hour  after 
meals. 

This  combination  has  proven  very  effective  in  relieving  the 
increased  intragastric  pressure,  relaxing  the  cardia,  and  per- 
mitting readier  belching,  with  symptomatic  relief.  Any  of 
the  stomachic  or  blood-building  tonics  may  be  adopted,  ac- 
cording to  the  symptomatic  indication,  and  their  use  is  often 
most  helpful. 

For  the  direct  treatment  of  the  associated  atony  and 
dilatation,  with  or  without  gastritis,  in  addition  to  the  use 
of  hygiene  and  dietetics,  lavage  supplemented  by  intragastric 
or  extragastric  faradism,  or  sinusoidalization,  will  prove  ex- 
tremely beneficial,  unless  contraindicated  for  reasons  of  gen- 
eral debility. 

A  few  words  in  regard  to  the  biologic-therapeutic  agent, 
tuberculin.  Since  first  introduced  by  Robert  Koch  in  1890, 
tuberculin  has  enjoyed  a  many-colored  reputation,  at  times 
brilliant,  and  for  many  years  somber.  At  the  end  of  a  ten- 
year  period  following  its  introduction,  its  use  was  generally 
discredited.  This  was  due,  no  doubt,  to  the  massive  dosage 
then  commonly  employed,  which  produced  severe  reactions, 
and  numerous  reports  were  published  stating  that  it  was  a 
dangerous  weapon,  and  had  a  tendency  to  hasten  tubercu- 


796  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

lous  (pulmonary)  lesions  to  caseation  and  cavity  formation. 
About  1905,  largely  due  to  the  efforts  of  Sir  Almroth  Wright, 
its  use  was  begun  again,  but  on  a  minimal  dosage  plan.  Since 
then  the  results  secured  have  been  undoubtedly  improved.  It 
has  had  far  greater  vogue  in  Europe,  especially  in  England, 
than  it  ever  enjoyed  in  this  country.  Indeed,  some  of  our 
most  eminent  experts  on  tuberculosis  have  never  used  it,  nor 
do  they  express  faith  in  its  efficiency.  The  writer  has  had  no 
personal  experience  with  it  as  a  therapeutic  agent,  and  should 
therefore  be  guarded  in  indorsing  its  use.  When  given  it 
should  be  administered  by  the  subcutaneous  method  (cer- 
tainly not  by  mouth),  and  in  minimal  ascending  doses,  by  one 
who  has  thoroughly  studied  such  authorities  as  Riviere  and 
Morland,'^'*  and  who,  possessed  of  a  thorough  knowledge  of 
the  indications  and  contraindications  for  its  use,  has  become 
familiar  with  the  fundamental  principles  of  its  technic. 

PYLOROSPASM. 

As  its  name  implies,  this  condition  is  one  in  which  the 
musculature  of  the  pylorus,  already  more  powerful  than  that 
occurring  at  anv  other  point  in  the  stomach,  suddenly  under- 
goes local  spasm,  which  occludes  the  lumen  of  the  p3doric 
exit  and  results  in  its  obstruction.  This  obstruction  is  often 
only  temporary,  but  may  result  permanently  if  gastric  atony 
or  ectasia  secondarily  develop. 

The  opening  and  closing  of  the  pylorus  is  controlled  by 
two  factors :  (a)  A  central  nervous  mechanism.  The  motor 
accelerating  fibers  of  the  pylorus  are  largely  derived  from  the 
vagi  and  the  inhibitory  fibers  from  the  cervical  splanchnics, 
and  these  or  their  combination  generalh-  make  up  the  pri- 
mary mechanism  of  respectively  closing  and  opening  the 
pyloric  orifices,  (b)  A  local  chemical  or  mechanical  reflex 
exerted  at  the  pylorus.  As  a  chemical  factor  it  is  found  that 
increased  concentration  of  the  gastric  juice  frequently  leads 
up  to  or  accompanies  pylorospasm,  causing  motor  delay ;  and, 
conversely,  relaxation  of  the  pylorus  occurs  with  increased 
motility  in  the  achylic  states,  except  when  due  to  cancer. 
Again,  as  a  mechanical  factor  the  ingestion  of  coarse  or  badly 
comminuted  foods  results  in  pylorospasm  due  in  part  to  the 


PYLOROSPASM.  797 

irritating  effect  such  coarse  foods  have  upon  a  localized 
pyloric  erosion  or  fissure.  Also  it  is  known  that  greasy  or  oily 
foods,  while  their  exit  from  the  stomach  is  normally  delayed, 
nevertheless  result  in  pyloric  relaxation,  and  permit  duodenal 
regurgitation.  This  fact  was  made  use  of  in  the  method  of 
recovering  duodenal  contents  after  the  ingestion  of  olive  oil 
or  cream ;  and  therapeutically  olive  oil  is  useful  in  controlling 
pylorospasm. 

Clinically,  pylorospasm  is  divided  into  those  cases  occur- 
ring as  a  primary  neurosis  due  to  irritation  of  the  vagi  (vagot- 
ony)  ;  secondly,  pylorospasm  due  to  a  localized  irritation,  as 
in  pyloric  or  duodenal  ulcer,  erosion  or  fissure ;  and,  thirdly, 
pylorospasm,  reflexly  induced  by  irritation  at  other  points 
of  the  midgut  or  its  derivatives,  notably  irritation  of  the 
biliary  apparatus  of  the  appendix. 

Pylorospasm  has  also  been  noted  in  cases  of  gastroptosia, 
prostatic  disease,  and  lesions  of  parts  of  the  female  productive 
apparatus.  The  last-named,  together  with  a  primary  neurosis, 
constitute  by  far  the  rarer  types  of  the  condition.  It  is  most 
commonly  associated  with  irritative  lesions,  ulcer,  erosion  and 
fissure,  located  at  or  near  the  pylorus,  and  next  most  com- 
monly caused  reflexly  by  inflammatory  irritation  of  the  biliary 
apparatus  or  the  appendix. 

The  symptoms  of  pylorospasm  are  quite  typical.  Usually 
at  the  height  of  digestion,  one  to  two  hours  after  a  mixed 
meal,  the  patient  experiences  a  sudden  spasmodic  cramp-like 
pain  in  the  epigastrium  at  the  pyloric  point,  which  may 
radiate  around  either  costal  margin  or  to  the  back,  is  soon 
followed  by  nausea,  and  in  cases  with  hyperacidity  a  burning 
epigastric  distress,  with  or  without  acid  regurgitation.  If  the 
condition  is  due  to  a  gross  dietetic  error,  in  which  the  pyloro- 
spasm is  a  protective  mechanism  of  nature  to  prevent  the  duo- 
denal or  intestinal  reception  of  an  improper  chyme,  vomiting 
may  occur  or  be  induced  after  which  the  spasmodic  pain  of 
pylorospasm  disappears,  and  the  other  sensations  of  epigastric 
distress  gradually  wear  away.  With  chronic  pylorospasm, 
where  pyloric  obstruction  has  continued  for  long,  the  symp- 
toms common  to  atony  and  ectasia  will  make  their  appear- 
ance— post-prandial  epigastric  sense  of  weight  and  pressure, 
with  bland,  sour,  or  acid  regurgitations  and  eructations. 


798  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

During  the  acute  attack  one  will  usually  find  a  tender 
point  in  the  epigastrium,  approximately  1  inch  (2.5  cm.)  to  the 
right  of  the  median  line,  and  from  1  to  2  inches  (2.5  to  5  cm.) 
above  the  navel.  In  patients  with  very  flaccid  abdominal 
walls  one  may  feel  the  spasmodically  contracted  pylorus,  and 
if  gentle  palpation  is  continued  the  pylorus  relax  is  frequently 
palpable,  and  the  little  tumor  will  disappear  from  beneath  the 
palpating  finger.  Indeed,  if  the  patient  is  greatly  emaciated 
and  the  abdominal  wall  is  thin,  this  spasmodic  contracture 
and  relaxation  of  the  pylorus  may  be  visible  through  the  ab- 
dominal wall,  and  has  frequently  been  observed  at  the  operat- 
ing table  during  a  laparotomy.  The  writer  saw  an  interesting 
case  in  Paul  Cohnheim's  clinic,  at  Berlin,  in  which  the  spastic 
pyloric  tumor  could  be  produced  at  will,  and  readily  palpated, 
after  forcible  pressure  had  been  made  over  the  sternomastoid 
muscles  to  irritate  hypertonic  vagi. 

Where  pylorospasm  is  reflexly  produced  from  g'all-bladder 
disease  it  is  important  to  determine  the  physical  findings 
common  to  such  condition,  such  as  stiffening  of  the  right  cos- 
tal arch  and  tenderness  to  palpation,  or  forcible  percussion 
over  the  gall-bladder,  with  rigidity  of  the  upper  right  rectus 
i^uscles.  In  cases  of  chronic  dyspepsia  with  pylorospasm  due 
to  an  appendiceal  irritation,  pressure  over  McBurney's  point 
frequently  gives  a  pain  definitely  referred  directly  to  the 
region  of  the  pylorus,  with  occasional  palpatory  evidence  of 
pylorospasm.  After  the  acute  symptoms  have  subsided  epi- 
gastric soreness  and  tenderness  to  pressure  persist  for  several 
days. 

The  chemistry  of  the  stomach  may  show  no  abnormality, 
particularly  when  interpreted  in  the  light  of  a  single  extrac- 
tion at  sixty  minutes,  but  by  the  fractional  method  it  is  more 
common  to  find  a  normal  first  hour  cycle  with  hyperacidity  be- 
coming evident  during  the  second  hour,  and  frequently  hyper- 
secretion demonstrable  during  the  third,  fourth,  and  fifth 
hours. 

The  prognosis  for  prompt  symptomatic  relief  is  very  good, 
except  in  cases  due  to  primary  neurosis  which  may  prove  very 
intractable  and  are  curable  only  by  the  restoration  of  a  proper 
nervous  balance.  In  cases  reflexly  dependent  upon  primary 
surgical   condition,   palliative    medicinal    measures   may   give 


PYLOROSPASM.  799 

symptomatic  relief,  l)ut  final  cure  cannot  he  expected  until  the 
aseptic  scalpel  has  done  its  work. 

TREATMENT. 

In  pylorospasm  due  to  a  primary  neurosis  the  underlying 
treatment  must  rest  upon  building-  up  the  general  nervous 
system  to  a  greater  plane  of  stability.  To  this  end  hygiene 
is  of  prime  importance.  An  abundance  of  fresh  air  by  day  and 
night,  moderate  exercise  in  the  open-air,  adopting  some  form 
of  exercise  that  is  attractive  to  the  individual,  are  to  be  ad- 
vised. Hydropathic  measures  are  useful,  such  as  the  morning 
cold  bath,  followed  by  a  salt  friction  rub.  In  this  connection 
a  simple  method  to  adopt  is  to  soak  a  rough  turkish  towel  in 
a  pail  full  of  brine  for  a  few  minutes,  allow  it  to  dry  rapidly 
so  that  the  salt  is  crystallized  out  and  becomes  enmeshed  in 
the  towel,  and  then  vigorously  rub  the  surface  of  the  body. 
Alternating  hot  and  cold  spinal  douches,  with  the  stream 
directed  particularly  over  the  third  to  eighth  dorsal  vertebrae 
to  stimulate  the  inhibitory  action  of  the  splanchnic  nerve  sup- 
ply to  the  stomach,  are  helpful  hydropathic  supplements. 
Intragastric  electricity,  particularly  the  sinusoidal,  and  to  a 
less  extent  the  galvanic,  current,  has  proven  useful  in  certain 
cases.  The  external  electrode  should  be  connected  to  the 
negative  pole,  and  be  in  the  form  of  a  pad  sufficient  to  cover 
the  third  to  the  eighth  thoracic  vertebrae.  Likewise,  a 
maneuver  suggested  by  Abrams  (loc.  cit.)  of  sustained  pres- 
sure by  means  of  a  bi-forked  pressor  instrument,  placed  over 
the  spinal  column  between  the  third  and  fourth  thoracic  verte- 
brae, will  relieve  pylorospasm  promptly,  but  is  a  much  more 
effective  procedure  in  acute  dilatation  of  the  stomach.  (C/. 
p.  824.) 

Nerve  sedatives,  such  as  the  bromids,  sumbul,  valerian, 
and  the  like,  may  be  given  for  short  periods  and  then  should 
be  followed  by  one  of  the  stimulating  tonics. 

In  pylorospasm,  when  due  to  a  local  irritation,  such  as 
ulcer,  erosion,  or  fissure,  the  treatment  must  be  more  direct. 
In  acute  pylorospasm  due  to  gross  dietetic  error,  and  in  all 
cases  in  which  the  pylorospasm  results  in  acute  pyloric  ob- 
struction, prompt  lavage  with  alkaline  solutions  to  rid  the 
stomach  of  its  offending-  irritatine  contents  is  extremelv  bene- 


800  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

ficial,  after  which,  if  the  pylorospasm  still  continues  in  its 
acute  form,  nothing  gives  more  prompt  relief  than  a  hypo- 
dermic of  ^4  grain  (0.015  Gm.)  of  morphin  with  %oo  of  a 
grain  (0.0006  Gm.)  of  atropin  sulphate,  after  which  further 
injections  of  atropin  sulphate  in  a  dosage  of  ^^200  to  %oo  oi  a 
grain  (0.0003  to  0.0002  Gm.)  should  be  given  every  second  or 
third  hour  until  the  symptoms  are  under  control  or  the  point 
of  physiologic  eftect  has  been  reached.  Local  applications  of 
heat  applied  to  the  epigastrium  are  very  grateful  to  the  pa- 
tient, but  in  pylorospasm  due  to  ulcer  with  a  history  of 
recent  bleeding  ice-cold  abdominal  applications  should  be  used 
instead.  (C/.  p.  697.)  For  one  or  two  days  no  food  should  be 
given  by  mouth,  and  nourishment  should  be  given'by  enemas 
and  the  use  of  proctoclysis. 

In  chronic  pylorospasm  due  to  a  chronic  calloused  pyloric 
ulcer,  especially  where  there  is  motor  obstruction  and  second- 
ar}^  hypersecretion,  surgical  interference  is  indicated  and  a 
p^dorectomy  or  a  pyloroplasty  are  more  effective  procedures 
than  a  gastrojejunostomy.  Where  the  pyloric  obstruction  is 
due  to  a  pylorospasm  with  secondary  inflammatory  edema  and 
not  to  a  chronic  stenotic  process,  such  as  a  cicatrix,  medical 
measures  may  be  carried  out  and  given  a  thorough  trial  be- 
fore surgery  is  attempted.  To  this  end  the  general  plan  of  the 
ulcer  cure  should  be  adopted. 

AMien  pylorospasm  is  reflexly  produced  from  irritative 
lesions  of  the  gall  bladder,  if  the  surgical  indications  for  oper- 
ative interference  are  not  deliniteK^  clear,  palliative  medicinal 
measures  may  be  adopted,  in  addition  to  the  steps  outlined 
above.  Urotropin  (hexameth3denamin)  may  be  given  in  a 
dosage  of  5  grains  (0.3  Gm.)  three  or  four  times  a  day,  and  a 
teaspoonful  (3.75  mils)  of  Carlsbad  salts  may  be  given  in  a 
tumblerful  of  hot  water  on  the  fasting  morning  stomach ;  also, 
one  may  gi^-e  5  grains  (0.3  Gm.)  of  the  inspissated  bile  salts 
thrice  daily,  two  hours  after  meals. 

When  pylorospasm  is  due  to  appendiceal  disease  operative 
interference  affords  the  only  means  of  permanent  relief,  and 
any  palliative  treatment  is  merely  postponing  the  inevitable. 
In  all  operations  in  the  upper  abdominal  zone  for  a  condition 
in  which  pvlorospasm  is  a  symptom,  whether  a  local  irritative 
lesion  is  or  is  not  found  at  the  pylorus  or  duodenum,  no  opera- 


PYLORIC   OBSTRUCTION.  801 

tion  Is  complete  unless  both  the  gall-bladder  region  and  the 
appendix  are  inspected  and  corrective  surgical  measures 
adopted.  In  certain  cases  the  writer  has  seen  pylorospasm 
continue  after  a  gastrojejunostomy  for  pyloric  or  duodenal 
ulcer,  and  only  cease  when  a  pathologic  appendix  was  removed 
at  a  subsequent  operation.  When  pylorospasm  is  reflexly  pro- 
duced by  gastroptosis,  wnth  a  dragging  pressure  exerted  on  a 
firmly  fixed  pylorus  or  duodenum,  the  symptom  usually  dis- 
appears when  the  stomach  is  elevated  to  a  better  position  by  a 
proper  abdominal  support. 

PYLORIC    OBSTRUCTION. 

The  etiologic  factors  of  pyloric  obstruction  are  herewith 
given  in  their  relative  order  of  frequency: 

1.  Cancer  or  sarcoma  of  the  pyloric  exit,  causing  obstruc- 
tion from  within ;  or  primary  cancer  or  sarcoma  of  the  neigh- 
borhood viscera,  causing  pyloric  obstruction  from  without. 

2.  Benign  agencies.  Pyloric  obstruction  secondary  to 
cicatricial  contraction,  from  a  pyloric  ulcer,  or  following  the 
ingestion  of  corrosive  substances, 

3.  Pylorospasm,  due  to  a  local  irritation  of  the  stomach 
(ulcer,  fissure,  etc.),  with  inflammatory  edema,  resulting  in 
obstruction. 

4.  A  pericholecystitis  or  pericholangitis  with  adhesions  to 
the  pylorus  or  duodenum,  or,  conversely,  peritoneal  adhesions 
to  the  neighborhood  viscera,  from  a  perigastritis  or  a  localized 
upper  abdominal  peritonitis. 

5.  Congenital  pyloric  stenosis  or  a  stenosing  gastritis. 

6.  Benign  tumors  of  the  stomach  obstructing  the  pylorus, 
chiefly  polypi  or  adenomata. 

In  the  early  stages  of  this  condition  the  most  conspicuous 
symptoms  are  those  of  motor  insufficiency  common  to  atony 
or  ectasia,  giving  a  sense  of  epigastric  pressure  and  heaviness 
occurring  at  varying  times  after  eating,  but  usually  reaching 
their  height  one  to  two  hours  after  taking  food,  depending 
largely  upon  the  amount  of  food  ingested.  This  epigastric 
weight  and  discomfort  are  accompanied  by  belching  or  food 
regurgitation  with  temporary  relief.  Nausea  mav  be  com- 
plained of,  but  as  a  rule  it  does  not  occur  until  accumulative 

51 


802  DISEASES   OF  THE   DIGESTIVE    SYSTEM. 

food  retention  has  taken  place.  The  frequency  of  vomiting 
will  of  course  depend  upon  the  degree  of  motor  insufficiency. 
In  the  lesser  grades  so  much  food  passes  through  the  pylorus 
that  the  retained  residue  is  comparatively  small,  and  may  re- 
quire several  days  for  a  sufficient  amount  of  food  to  collect 
that  provokes  voluntary  or  induced  vomiting.  As  the  ob- 
struction increases,  less  food  is  able  to  pass  the  pylorus  at 
any  given  meal,  and  retention  or  collective  vomiting  may 
occur  daily  or  every  second  day.  When  this  point  is  reached 
fermentative  processes  usually  have  begun,  and,  in  addition, 
the  patient  will  show  progressive  loss  of  weight,  due  to  in- 
anition, through  failure  of  food  to  reach  the  intestines  and  be 
absorbed.  Thirst  is  usually  complained  of,  and  the  degree 
of  retention  can  frequently  be  gaged  by  the  diminution  of  the 
daily  urinary  output.  When  the  urine  output  has  decreased  to 
500  mils  (16  fg),  in  the  absence  of  a  primary  nephritis,  the 
obstruction  has  reached  a  very  severe  grade.  In  hyperacid 
cases,  pyrosis  and  acid  regurgitations  are  usually  complained 
of,  and  if  there  is  an  associated  hypersecretion  the  amount  of 
fluid  in  the  retention  vomiting  will  be  materially  increased. 

The  chemical  and  microscopic  examinations  in  pyloric  ob- 
struction due  to  cancer  show  the  hydrochloric  acid  elements 
generally  diminished  or  absent^  and  the  presence  of  lactic  acid, 
the  Oppler-Boas  bacillus,  and  occult  bleeding  can  usually  be 
demonstrated.  In  pyloric  obstruction  due  to  benign  causes 
the  hydrochloric  acidities  are  likely  to  be  higher,  and  butyric 
and  acetic  acid,  with  high  fermentation  tests,  and  sarcinae  are 
usually  present.  The  diagnosis  and  the  degree  of  pyloric  ob- 
struction can  best  be  determined  by  a  series  of  motor  test- 
meals. 

The  prognosis  is  always  grave,  but  will  vary  according  to 
the  etiological  factors  involved, 

TREATMENT. 

With  the  exception  of  pylorospasm  with  obstructive  in- 
flammatory edema,  and  with  the  possible  exception  of  a  local- 
ized upper  abdominal  .peritonitis,  particularly  if  chronic  or 
subsiding,  the  treatment  is  entirely  surgical.  Such  surgery 
may  consist  of  a  pylorectom}'',  a  partial  gastrectomy  either 
with  or  without  a  gastrojejunostomy,  or  a  gastrojejunostomy 


PYLORIC  OBSTRUCTION.  803 

alone,  the  operative  choice  being  dependent  upon  the  in- 
dividual operative  mechanics,  the  comparative  risks  in  each 
type  of  operation  and  the  age  and  condition  of  the  patient. 
This  particularly  applies  to  pyloric  obstruction  due  to  malig- 
nancy and  to  congenital  pyloric  stenosis. 

When  due  to  ulcer  or  to  inflammatory  adhesions  associated 
with  biliary  diseases,  the  choice  of  the  most  favorable  opera- 
tion must  be  modified  to  meet  the  requirements  of  the  in- 
dividual case.  Benign  tumors  of  the  stomach  that  have  a  tend- 
ency to  develop  from  the  mucous  membrane  and  obstruct  the 
gastric  lumen,  the  adenomas  and  polyps  particularly,  rarely 
need  radical  resection,  and  many  of  the  cases  reported  have 
been  sufficiently  localized  to  be  removed  through  a  gastro- 
scope.  In  the  writer's  opinion,  however,  this  type  of  operative 
treatment  is  more  heroic,  and  carries  a  greater  operative  risk, 
even  when  practised  in  the  most  experienced  hands,  than  does 
direct  surgery  following  laparotomy. 

Where  pyloric  obstruction  is  due  to  pylorospasm  with  in- 
flammatory edema,  and  if  not  due  to  reflex  surgical  lesions  of 
the  gall-bladder  or  appendix,  the  medicinal  management,  as 
discussed  on  page  799,  should  be  given  a  thorough  trial  for  at 
least  a  week  before  surgical  interference  should  be  considered. 

The  degree  of  pyloric  obstruction  may  give  the  indication 
for  the  urgency  of  operative  interference.  This  naturally  does 
not  apply  to  cancer,  the  radical  cure  of  which  primarily  de- 
pends upon  immediate  operation.  Where  cancer  can  be 
reasonably  excluded,  a  few  days  of  delay,  while  palliative 
measures  are  being  tried,  will  not  materially  increase  the  later 
operative  risk  to  the  patient,  and  the  writer  is  coming  more 
and  more  to  the  belief  of  the  need  of  giving  patients  who  re- 
quire gastric  surgery,  particularly  those  showing  motor  in- 
sufficiency, a  week  or  ten  days  of  preliminary  medical  treat- 
ment with  bed-rest,  daily  lavage,  and  the  use  of  external  ab- 
dominal applications.  By  a  few  days  of  such  treatment,  in 
association  with  the  other  measures  detailed  elsewhere  (Cf. 
p.  799),  one  can  usually  decide  in  a  given  case  of  pyloric  ob- 
struction how  much  is  due  to  pylorospasm  with  inflammatory 
edema,  and  whether  under  the  circumstances  a  continuance  of 
such  medical  management  would  be  warranted. 


804  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

CONGENITAL    PYLORIC    STENOSIS. 

In  view  of  the  still  continued  dispute  as  to  its  etiology, 
congenital  pyloric  stenosis  might  better  be  termed  "hyper- 
trophic pyloric  stenosis  of  infants." 

The  nature  of  this  dispute  revolves  around  two  theories, 
each  of  which  has  been  supported  by  loyal  adherents.  The 
first  of  these  theories  is  that  the  hypertrophy  affecting  the 
circular  muscular  fibers  of  the  pylorus  is  congenital.  It  is 
caused  by  abnormal  proliferation  of  this  muscle  layer  during 
fetal  life,  and  in  the  few  days  or  weeks  that  elapse  after  birth, 
prior  to  the  development  of  symptoms,  and  secondary  to  this 
congenital  hypertrophy  a  pylorospasm  develops  simultane- 
ously with  the  appearance  of  symptoms.  The  supporters  of 
this  theory  of  congenital  development  base  their  belief 
largely  upon  the  ground  that  a  degree  of  hypertrophy,  such  as 
exists  in  most  cases,  could  not  have  occurred  as  a  work  hy- 
pertrophy secondary  to  pylorospasm,  in  the  few  days  or  weeks 
that  have  elapsed  since  birth.  The  opponents  of  this  theory, 
however,  point  to  the  absence  of  any  recorded  cases  of  over- 
development of  the  pyloric  musculature  seen  in  autopsies  on 
the  fetus. 

The  second  theory  concerns  itself  with  the  premise  that 
the  condition  is  primarity  a  pylorospasm,  reflexly  or  locally 
produced  (e.g.,  pyloric  ulcer,  erosion,  or  fissure)  with  a  sec- 
ondary hypertrophy  of  the  pyloric  muscles  as  nature's  at- 
tempt to  overcome  the  obstruction.  The  opponents  of  this 
theory  believe  that  if  such  were  the  case  there  should  be 
evidence  of  hypertrophy  of  the  longitudinal  as  well  as  the 
circular  muscle  coats,  and  they  ask  why,  in  analogous  cases 
of  spasm  of  the  sphincter  ani,  due  to  anal  ulcers  or  erosions, 
there  does  not  occur  secondary  hypertrophy  of  the  rectal  mus- 
cles on  the  proximal  side  It  will  probably  clarify  the  situa- 
tion to  assume  that  these  two  theories  are  conflicting  simply 
because  they  are  not  attempting  the  description  of  the  same 
clinical  entity. 

There  has  been  an  attempt  to  classify  the  cases  Into  two 
groups : 

1.  Cases  of  primar)^  pylorospasm  with  secondary  hyper- 
trophy.   These  show  milder  gradation  of  symptoms,  and  have 


CONGENITAL    PYLORIC    STENOSIS.  805 

largely  been  considered  medical,  inasmuch  as  many  respond 
satisfactorily  to  medical  measures  designed  to  allay  primary 
pylorospasm  and  pylorospasm  secondary  to  pyloric  ulcer. 

2.  Cases  of  congenital  hypertrophy  of  the  circular  mus- 
cular fibers  of  the  pylorus,  with  added  pylorospasm  occur- 
ring- as  a  secondary  factor.  Such  cases  rapidly  develop  a  much 
more  serious  aspect,  and  are  generally  to  be  considered  a  sur- 
gical problem  for  the  reason  that  they  do  not  prove  amenable 
to  successful  medical  management. 

From  a  strictly  etiologic  standpoint  such  a  classification  is 
not  justifiable,  if  one  presents  the  subject  with  a  title  of  con- 
gcnital  pyloric  stenosis.  Nevertheless,  such  a  distinct  clinical 
entity  undoubtedly  exists  in  which  the  pyloric  hypertrophy  is 
prenatal  in  origin  One  of  the  best  arguments  in  favor  of  this 
is  that  cases  have  been  observed  (Holt)  in  which  the  pyloric 
hypertrophy  was  found  post-mortem  from  two  to  five  years 
after  gastro-enterostomy,  in  children  who  subsequently  died 
from  other  causes.  It  is  scarcely  conceivable  that  a  work 
hypertrophy,  secondary  to  spasm,  would  persist  so  long  after 
the  primary  cause  has  been  removed.  It  should  also  be  re- 
membered that  even  if  the  hypertrophy  is  strictly  congenital, 
it  may  occur  in  all  degrees  from  the  mildest  to  the  most  severe. 

To  Beardsley,  who  in  1788  reported  a  case  with  post- 
mortem findings,  certainly  belongs  the  credit  for  the  first 
accurate  description  of  this  disease.  Half  a  century  later 
additional  cases  were  reported,  but  the  attention  of  the  medical 
profession  was  not  drawn  to  the  frequency  of  this  condition 
until  the  publications  of  Hirschsprung,  of  Copenhagen,  in 
1888,  and  it  is  to  him  that  we  principally  owe  our  modern 
conception  of  this  disease. 

The  most  authoritative  resume  of  the  entire  subject  has 
been  recently  published  by  Emmett  Holt,^^  to  whom  the 
writer  cordially  acknowledges  his  indebtedness  for  the  sur- 
gical data  in  connection  with  this  section. 

At  operation  or  at  autopsy  the  pylorus  is  found  to  be  hy- 
pertrophied,  and  appears  as  a  cartilaginous  cylinder  extending 
from  the  pyloric  ring  1  to  2  inches  '(2.5  to  5  cm.)  toward  the 
gastric  side  of  the  pylorus,  and  pouting  into  the  duodenum, 
much  as  the  cervix  uteri  projects  into  the  vagina.  On  section 
the  muscular  wall  is  seen  to  be   greatly  thickened   and  the 


806  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

hypertrophy  limited  to  the  circular  muscular  fibers  together 
with  the  hypertrophy  of  the  pyloric  mucosal  folds.  There  is 
often  secondary  edema.  The  color  is  a  pearly  white,  and  is 
notable  for  its  bloodless  appearance ;  the  pylorus  and  pyloric 
ring"  are  stenotic,  and  may  barely  admit  the  passage  of  the 
smallest  probe,  largely  because  of  the  secondary  hypertrophy 
of  the  mucosal  folds  with  the  superadded  edema.  The  rest 
of  the  stomach  is  usually  found  to  be  considerably  dilated,  as 
the  consequence  of  a  secondary  process. 

The  great  majority  of  these  cases  run  true  to  form  and 
show  a  marked  similarity  of  symptoms.  The  history  obtained 
is  exceedingly  important,  and  is  usually  that  of  a  breast-fed 
infant,  most  commonly  a  male,  born  in  perfect  health  and 
remaining  so  for  several  days  or  several  weeks,  rarely  exceed- 
ing ten.  According  to  Holt's  observations,  the  onset  of  symp- 
toms is  likely  to  occur  between  the  second  and  third  weeks 
of  life..  After  taking  the  breast  well  such  an  infant  suddenly 
begins  to  vomit,  and  this  occurs  daily.  The  vomitus  at  first 
is  usually  small  in  amount,  and  consists  entirely  of  the  in- 
gested food  with  no  evidence  of  biliary  regurgitation.  In  a 
few  days,  according  to  the  rapidity  with  which  secondary 
dilatation  develops,  accumulative  or  retention  vomiting  oc- 
curs, and  can  be  readily  determined  from  the  fact  that  the 
quantity  of  the  ejected  material  is  considerably  greater  than 
the  amount  given  at  the  last  feeding.  Vomiting  usually  oc- 
curs shortly  after  the  feeding,  and  is  probably  due  to  second- 
ary pylorospasm,  which  is  almost  invariably  an  associated 
feature  in  these  cases.  The  stomach  is  highly  irritable,  and 
peristalsis  is  active  until  atonic  dilatation  has  occurred.  The 
vomiting  is  projectile  in  type,  may  be  ejected  through  the 
nostrils  as  well  as  the  mouth,  and  may  project  for  a  distance 
of  several  feet.  Shortty  after  vomiting  has  begun  the  infant 
begins  to  lose  weight,  at  first  slowly,  and  later  ver}^  rapidly, 
frequently  reaching  a  state  of  extreme  emaciation  in  a  very 
few  days,  if  the  condition  is  unrecognized  or  unarrested.  The 
bowels,  as  a  rule,  become  very  constipated.  This  is  of  diag- 
nostic value,  inasmuch  as  m  most  other  conditions  of  infantile 
vomiting  there  is  the  associated  diarrhea  of  enteritis.  The 
microscopic  examination  of  the  fecal  residue  shows  a  diminu- 


CONGEiNiTAL    PYLORIC    STENOSIS.  807 

tioii  of  food  elements,  and  the  urine  l)ecomes  scanty  and  high- 
colored  owing-  to  the  lack  of  retention  of  ingested  fluids. 

The  objective  findings  are  likewise  characteristic.  Test- 
meals  of  2  or  3  ounces  (30  or  60  mils)  of  breast  milk  or  con- 
densed milk  may  be  recovered  one  or  two  hours  later  in  prac- 
tically the  full  amount,  indicating  pyloric  obstruction.  For 
this  purpose  Holt  recommends  the  use  of  a  soft  rubber 
catheter,  attached  to  one  end  of  a  T-tube  inserted  through  the 
cork  of  an  ordinary  laboratory  specimen  bottle,  to  the  other 
end  of  which  is  attached  a  suction  tube,  by  means  of  which 
gentle  aspiration  of  gastric  contents  can  be  made  by  direct 
mouth  suction.  The  most  important  objective  finding  is  the 
observation  of  waves  of  gastric  peristalsis,  running  down- 
ward from  left  to  right.  This  is  an  almost  invariable  finding, 
although  it  may  require  considerable  patience  and  frequent 
observation  before  it  is  noted  in  some  cases,  and  while  pathog- 
nomonic is  by  no  means  indispensable  to  the  making  of  the 
diagnosis.  Its  presence  depends  to  a  certain  extent  upon  the 
degree  of  emaciation.  Such  a  tumor  is  felt  as  a  cartilaginous 
ring  or  cylinder  about  the  size  of  a  hazel  nut,  at  a  point  usu- 
ally just  above  and  to  the  right  of  the  navel. 

The  diagnosis  in  most  cases  should  be  easy,  inasmuch  as 
the  symptoms  are  so  uniformly  characteristic.  In  the  order 
of  their  diagnostic  importance,  Holt  classifies  the  symptoms 
and  objective  findings  in  the  following  order: 

1.  The  history  if  intelligently  given  and  taken.  A  his- 
tory of  a  healthy  born,  usually  breast-fed  male  infant,  with 
the  abrupt  onset  of  vomiting  of  a  projectile  and  progressive 
type ;  and  the  appearance  of  symptoms  within  a  few  days  to  a 
few  weeks  after  birth,  but  much  more  commonly  between  the 
second  and  third  weeks  of  life. 

2.  A  determination  of  abnormal  gastric  retention  indi- 
cative of  pyloric  obstruction. 

3.  Visible  peristaltic  waves,  provided  they  are  typical. 

4.  The  presence  of  a  palpable  tumor. 

5.  The  associated  symptoms  of  wasting^,  constipation, 
and  scanty  urine. 

Diagnosis  by  means  of  .x'-ray  plate  or  fluoroscopic  examina- 
tion is  not  essential,  inasmuch  as  little  more  in  the  way  of 


808  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

direct  confirmation  can  be  gained  which  cannot  be  deduced 
from  the  history  and  cHnical  obser\'ation,  and  because  these 
measures  add  a  certain  element  of  risk,  and  cause  unnecessary- 
fatigue. 

The  difterential  diagnosis  is  concerned  itself  chiefly  with 
these  two  conditions : 

1.  Pylorospasm  secondary  to  duodenal  or  pyloric  ulcer, 
in  which  there  may  be  seen  the  visible  peristalsis.  These 
cases,  however,  give  quite  a  different  history.  There  is  not 
the  evidence  of  persistent  pyloric  obstruction,  a  greater  tend- 
ency to  hypersecretion  exists,  visible  or  occult  bleeding  in 
gastric  filtrate  or  in  the  feces  is  usually  demonstrable,  and  un- 
less the  pylorospasm  is  continuousl}^  persistent  considerably 
less  wasting  from  inanition  occurs. 

2.  Gastric  indigestion  or  gastro-enteric  indigestion  of 
various  types  with  proctracted  vomiting  and  subsequent 
emaciation.  Here  the  diagnosis  is  made  by  the  exclusion  of 
the  other  characteristic  symptoms,  common  to  congenital 
pvloric  stenosis.  The  vomiting  is  not  so  persistent  or  extreme 
and  there  is  usually  no  evidence  of  a  high-grade  pyloric  ob- 
struction, the  characteristic  constipation  is  usualh^  replaced  by 
a  bloody  and  mucous  diarrhea  secondary  to  enteritis,  and  the 
stools  are  sour,  fermentative,  and  greenish-A^ellow  instead  of 
the  hard  and  dry,  as  in  pyloric  stenosis  due  to  absence  of 
fluids  in  the  intestines. 

In  view  of  the  advances  in  diagnosis  and  treatment  the 
prognosis  has  become  much  less  grave  than  was  formerly 
justifiable.  The  mortality  has  decreased  about  25  per  cent, 
with  improved  surgical  technic  and  a  perfected  follow-up 
treatment. 

TREATMENT. 

The  character  of  treatment  in  the  final  analysis  resolves 
itself  entirely  into  a  matter  of  judgment  whether  any  given 
case  should  be  managed  medically  or  surgically.  In  recent 
years  a  few  series  of  cases  have  been  published  in  which  many 
successful  recoveries  have  been  reported  by  the  adoption  of 
many  perfected  medical  plans.  Nevertheless,  the  mortality  here 
ranges  from  30  to  50  per  cent.  Furthermore,  it  is  probably 
true  that  most  of  these  reported  medical  recoveries  occurred 


CONGENITAL   PYLORIC   STENOSIS.  809 

in-  cases  exhibiting  milder  grades  of  the  disease,  or,  indeed, 
cases  of  primary  pylorospasm  or  secondary  to  pyloric  or  duo- 
denal ulcers,  fissures,  or  erosions.  If  this  be  a  fact  the  latter 
group  cannot  be  classified  as  congenital  pyloric  stenosis.  In 
the  writer's  opinion,  even  such  cases  as  give  classically  char- 
acteristic symptoms  cannot  be  as  accurately  diagnosed  as 
those  cases  which  come  to  the  operating  or  autopsy  table. 

If  a  medical  plan  is  adopted,  it  should  be  continued  only  to 
such  a  po;nt  as  shows  a  persistent  and  steady  improvement. 
Cases  that  do  not  show  an  immediate  gain  in  weight,  or  that 
progress  badly  should  not  be  temporized  with  until  progres- 
sive weakness  and  emaciation  mitigate  against  later  success- 
ful operative  interference.  On  the  other  hand  the  writer 
agrees  with  Koplik,^^  that  unless  a  surgeon  of  experience  and 
technical  skill  is  available  it  may  be  wiser  to  continue  the 
medical  management.  This  view  must,  however,  be  some- 
what modified  from  the  fact  that  at  the  time  of  Koplik's  pub- 
lication a  gastrojejunostomy  was  considered  to  be  the  opera- 
tion of  choice,  and  required  approximately  from  one-half  to 
three-quarters  of  an  hour  for  its  performance ;  whereas  the 
operation  of  choice  today  is  that  devised  by  Rammstedt,  which 
has  proven  vastly  more  efficient,  can  be  carried  out  with  great 
celerity,  and  has  reduced  the  surgical  mortality  by  nearly  30 
per  cent.    This  operation  will  be  discussed  in  later  paragraphs. 

The  essentials  of  medical  treatment  may  be  summarized 
as  follows : 

1.  Feeding.  If  the  infant  is  breast-fed  it  is  by  far  better 
not  to  wean  it,  but  it  is  of  an  advantage  to  pump  the  breast 
and  feed  tlie  baby  at  hourly  intervals  in  small  amounts  by 
means  of  a  medicine  dropper.  It  is  needless  to  say  that  the 
quality  of  the  mother's  milk  should  be  promptly  analyzed  to 
determine  its  suitability.  If  the  baby  has  been  bottle-fed  on 
modern  scientific  plans,  and  still  shows  persistent  loss  of 
weight,  it  is  better  to  substitute  a  properly  selected  wet-nurse. 
It  should  be  seen  that  both  the  breast  milk  and  any  modified 
feeding  formulas  should  be  relatively  low  in  fat. 

2.  Lazfage.  The  stomach  should  be  lavaged  twice  a  dav 
before  feedings  by  means  of  a  soft  catheter  and  glass  funnel. 

3.  Bozi'els.  The  bowels  should  be  moved  exclusivel}-  by 
enemas,  and  this  should  be  followed  by  proctoclysis  with  a 


810  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

solution  of  decinormal  soda  bicarbonate,  to  which  may  be 
added  2^  to  5  per  cent,  of  glucose. 

4.  Local  Applications.  .  Heat  should  be  applied  constantly 
to  the  abdomen  in  the  form  of  hot,  moist  compresses,  over 
which  may  be  placed  a  soft  felt  pad  electrically  heated. 

5.  Weight.  The  infant  should  be  weighed  daily,  and  the 
weight  carefully  recorded.  If  any  good  is  to  be  accomplished 
by  a  medical  management,  it  will  be  promptly  seen  in  the 
cessation  of  the  vomiting  and  a  prompt  gain  in  weight. 

CARDIOSPASM. 

Cardiospasm,  once  thought  to  be  a  rare  disease,  is  being 
recognized  much  oftener  on  account  of  our  increasing  familiar- 
ity with  its  symptoms  and  the  technical  measures  necessary 
for  its  direct  diagnosis. 

The  etiolog}'  of  cardiospasm  is  varied,  man}^  causes  having 
been  adA'anced,  all  doubtless  capable  of  proof  in  certain  cases. 
The  following  causes  have  been  suggested : 

1.  Primary  cardiospasm.     (]\Ieltzer.) 

2.  Primary  esophagitis.     (]\Iartin.) 

3.  Primary  atony  of  the  esophageal  musculature.  (Rosen- 
heim.) 

4.  Functional  disturbance  of  the  innervation  of  the  esoph- 
agus due  to  paralysis  of  the  vagus  causing  simultaneous 
spasm  and  atony  of  the  musculature  of  the  esophagus. 
(Kraus.) 

5.  Congenital  disposition.  (Fleiner,  Zenker,  Luschka  and 
Sievers.) 

6.  Kinking  at  the  hiatus  esophagei.     (Plummer.) 
Bassler  has  recently  published  an  article  in  which  he  puts 

forAvard  the  view  that  cases  exhibiting  obstruction  at  the 
lower  end  of  the  gullet,  of  the  type  which  we  have  hitherto 
thought  to  be  cardiospasm,  are  not  cardiospasm,  but  rather 
"a  spasm  of  the  esophageal  opening  of  the  diaphragm  due  to 
contraction  of  the  muscular  fibers  of  the  crura,  which  contracts 
the  esophageal  opening  by  drawing  the  central  tendon  of  the 
diaphragm  against  the  front  of  the  esophagus  or  contracts  it 
at  the  sides." 

In  support  of  this  view,  which  is  based  on  a  dissection  of 


CARDIOSPASM.  811 

5  fresh  cadavers  and  Rontgen-ray  observations  of  7  cases  of 
cardiospasm,  lie  seems  able  to  prove  (1)  that  "the  lower  ex- 
tremity of  the  esophagus  or  cardiac  orifice  of  the  stomach 
have  no  or  only  a  faintly  developed  sphincter,"  and  (2)  that 
the  stricture  is  almost  always  epicardial,  usually  occurring  at 
a  distance  of  one  vertebra  above  the  cardiac  orifice  of  the 
stomach,  which  corresponds  to  the  esophageal  opening  of  the 
diaphragm. 

Bassler  offers  no  etiologic  factors  tending  to  produce 
this  diaphragmatic  contraction  of  the  esophageal  opening. 
While  his  paper  throws  a  new  light  upon  the  subject,  it  would 
appear  to  be  one  concerning  proper  nomenclature,  affecting 
somewhat  the  pathology,  but  not  altering  appreciably  the 
symptomatology  or  therapy  of  what  we  now  call  cardiospasm. 

Under  normal  conditions,  we  know  that  food  on  entering 
the  esophagus  requires  from  seven  to  ten  seconds  to  pass  into 
the  stomach ;  about  one-seventh  to  one-quarter  of  this  time  is 
required  for  food  to  pass  down  to  the  cardiac  portion  of  the 
esophagus,  where  it  remains  for  several  seconds  until  the  car- 
diac sphincter  relaxes,  and  the  food  passes  into  the  stomach 
by  the  peristaltic  contraction  of  the  circular  and  longitudinal 
fibers  of  the  esophageal  muscles.  We  have  ample  proof  of 
this  (1)  in  the  Rontgen-ray  studies  of  Kronecker  and  Melt- 
zer,  Cannon  and  Moser,  and  others  (2)  by  the  common 
personal  observation  of  experiencing  the  sudden  aching  pain 
of  momentary  duration  felt  back  of  the  sternum  in  its  lower 
third  on  swallowing  too  hot  or  too  cold  foods,  such  as  soup, 
coffee,  or  ice  cream,  and  (3)  by  the  post-mortem  evidence,  after 
the  ingestion  of  corrosive  poisons,  that  the  greatest  amount 
of  erosion  in  the  esophagus  occurs  at  its  lower  third  in  the 
neighborhood  of  the  cardia,  where  contact  with  the  corrosives 
has  been  longest  sustained. 

While  there  is  this  normal  delay  of  foods  at  the  cardia, 
this  varies  also  with  the  character  of  the  food,  its  temperature 
and  chemical  concentration,  the  extremes  of  all  these  causing 
a  variable  inhibition  of  the  dilating  mechanism  of  the  cardia. 

Idiopathic  or  primary  cardiospasm  occurs  frequently,  as  is 
seen  so  often  in  hysteria  and  in  those  of  neurotic  temperament 
and  tendencies,  and  is  here  purely  functional ;  but  if  of  fre- 
quent occurrence  it  permits  more  and  more  retention  of  foods, 


812  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

often  irritating-  in  character  and  composition,  for  too  long  a 
time  in  the  neighborhood  of  the  cardia,  predisposing  to  the 
de^■elopment  of  esophagitis  of  varied  types,  erosions,  fissures 
and  ulcerations.  Thus  a  vicious  circle  is  produced,  the  local 
inflammation  disposing  to  cardiospasm,  and  the  spasm  per- 
mitting of  unduly  long  retention  of  foods  at  the  cardia,  thereby 
increasing  the  esophagitis. 

The  commonest  forms  of  cardiospasm  are  primary  cardio- 
spasm of  a  purely  functional  type,  and  constituting  a  local 
neurosis,  or  a  manifestation  of  a  general  neurosis,  and  primary 
esopliagitis;  but  when  both  cardiopasm  and  esophagitis  can 
be  demonstrated  simultaneous!}*,  it  is  extremel}-  difficult  to 
decide  which  is  the  primary  lesion. 

Of  the  other  etiologic  factors,  congenital  disposition  may 
be  an  active  element  in  certain  isolated  cases.  Indisputable 
proof  of  this,  however,  should  be  furnished  by  the  history  and 
the  absence  of  all  other  etiolgic  factors  before  one  could  feel 
reasonably  safe  in  assigning  this  as  the  cause.  Likewise,  pri- 
mary atony  of  the  esophagus,  while  it  may  occur  rareh^,  is 
probabty  also  a  less  common  factor  in  the  etiology.  Plum- 
mer,'^'  to  whom  we  are  largely  indebted  for  our  better  under- 
standing of  this  condition,  concludes  from  a  study  of  his  cases, 
that  primar}-  atony  of  the  esophageal  musculature  is  of  rare 
occurrence,  stating  that  in  his  cases  "the  almost  invariable  his- 
tory' of  spasm  at  the  onset,  followed  in  the  later  period  by  the 
evidence  of  dilatation — that  is,  retention  of  food  in  the  eso- 
phagus— is  most  convincing  evidence  that  the  spasm  precedes 
the  dilatation,  and  that  primar}-  atony  is  rare."  Functional 
disturbances  of  the  innervation  of  the  esophagus,  due  to  the 
paralysis  of  the  vagus,  and  kinking  at  the  hiatus  esophagei, 
also  appear  to  be  unusual  etiologic  factors. 

There  are  undoubtedly  many  cases  of  cardiospasm  so  slight 
as  not  to  give  rise  to  any  symptoms,  and  in  such  instances  the 
diagnosis  can  be  established  only  by  mechanical  means.  The 
first  subjective  symptom  usually  volunteered  by  the  patient 
is  a  sensation  of  discomfort  felt  behind  and  usually  to  the  left 
of  the  sternum.  This  is  variously  described  as  a  dull,  aching 
pain,  that  throbs,  burns,  cuts,  or  has  a  sense  of  pressure  or 
weight,  as  if  something  had  lodged  low  down  in  the  gullet. 
These  symptoms  occur  onh^  during  the  ingestion  of  food,  and 


CARDIOSPASM.  813 

at  first  may  be  of  short  duration,  with  periodic  remissions 
during-  which  the  patient  is  aljle  to  eat  freely  and  without 
dysphagia. 

During  this  period  the  esophageal  musculature  is  suf- 
ficiently strong  to  overcome  the  spasm  and  to  permit  of  the 
entrance  of  food  into  the  stomach  with  only  momentary  delay. 
As  the  condition  progresses,  compensatory  hypertrophy  of  the 
musculature  must  develop  to  overcome  the  increasing  obstruc- 
tion, and  here  a  second  symptom  makes  its  appearance,  namely, 
the  regurgitation  of  foods  from  the  esophagus  into  the  mouth, 
very  shortly  after  their  ingestion,  due  to  the  overactive  con- 
tracting efi:orts  of  the  esophag^eal  musculature.  The  regurgi- 
tated foods  in  this  stage  may  be  both  liquid  and  solid,  return- 
ing in  practically  the  same  condition  as  when  eaten,  and  not 
unpleasant  in  taste  or  odor.  The  majority  of  ingested  food  is 
passed  through  the  cardia  slowly,  but  nevertheless  surely,  so 
long-  as  the  hypertrophied  muscle  is  competent  to  overcome 
the  obstruction.  Gradually  the  muscles  tire  under  their  extra 
load,  and  rupture  of  the  muscle  bundles  takes  place  with  a 
resultant  dilatation.  At  this  stage  the  regurgitation  of  food 
may  be  temporarily  less  frequent,  and  occur  at  somewhat 
longer  intervals  after  it  is  swallowed.  As  the  dilatation  be- 
comes more  extreme,  the  esophageal  capacity  becomes  greater, 
and  capable  of  retaining  larger  quantities  of  food,  which  are 
likely  to  be  regurgitated  only  when  the  patient  is  lying  down, 
.stooping  over,  or  during  a  paroxysm  of  coughing".  The  dila- 
tation of  the  esophagus  in  time  may  become  extreme,  with  a 
capacity  well  over  a  pint  (500  mils).  Since  the  propulsive 
power  of  the  esophageal  muscle  is  lacking,  food  can  only  pass 
into  the  stomach  slowly  even  when  the  spasm  has  been  re- 
laxed, and  in  proportion  to  the  weight  of  the  column  of  food 
in  the  esophagus,  assisted  by  gravity.  The  liquid  portion  of 
the  meal  usually  passes  more  rapidly,  seeping-  through  the 
solid  portion  so  as  to  leave  a  dense  pultaceous,  often  foul- 
smelling  mass,  usually  incorporated  with  tenacious  mucus, 
which  gives  rise  to  a  continual  sensation  of  pressure  and  ful- 
ness behind  the  sternum,  with  occasional  difficulty  in  breath- 
ing, due  to  pressure  on  the  trachea.  As  food  products  are 
retained  for  longer  and  longer  periods  within  the  esophagus, 
fermentation  and  decomposition,  chemical  and  bacterial,  take 


814  DISEASES    OF   THE   DIGESTIVE    SYSTEM. 

place,  and  this  results  in  secondary  esophagitis.  At  this  stage 
the  condition  of  some  patients  is  truly  deplorable ;  they  suffer 
continually  with  a  sense  of  burning  pressure  back  of  the 
sternum ;  they  are  able  to  eat  only  small  quantities  of  food  at 
a  time,  and  their  total  amount  of  food  ingested  and  assimilated 
is  so  small  that  they  lose  weight  rapidly;  and  if  not  relieved 
may  develop  a  profound  cachexia  and  die,  literally  of  starva- 
tion. 

The  symptom-complex  is  usually  so  characteristic  as  to 
suggest  the  diagnosis,  although  I  must  confess  that  it  is  not 
always  so  easy  as  it  sounds. 

The  direct  diagnosis  can  always  be  made  by  the  use  of  an 
esophageal  bougie,  preferably  of  the  Plummer  type,  very  often 
by  means  of  the  stomach  tube,  or  by  fluoroscopic  study  and 
Rontgen-ray  plate  analysis. 

In  the  early  stages,  with  the  use  of  the  esophageal  bougie 
or  of  the  stomach  tube,  it  will  be  found  that  an  obstruction  to 
the  further  passage  of  the  instrument  in  adults  is  met  with  at 
about  16  or  17  inches  (40.6  or  43.2  cm.)  from  the  incisor  teeth. 
The  instrument  can  be  passed  readily  until  this  point  is  reached, 
when  an  elastic-like  obstruction  is  met  with,  which,  under  firm 
and  steady  pressure,  usually  gives  way,  and  permits  of  the 
passage  of  the  bougie  or  stomach-tube. 

During  the  periodic  remissions  the  obstruction  will  not  be 
met  with,  or  at  times  the  bougie  or  tube  seems  about  to  pass 
when  it  is  suddenly  gripped  in  the  spasm  of  the  contracting 
muscle,  excited  by  the  instrumentation.  Great  care  should  be 
practised  in  attempting  to  pass  the  instrument  beyond  the  ob- 
struction until  the  diagnosis  of  cardiospasm  is  definitely  made 
to  the  exclusion  of  diverticuli,  a  kinking  at  the  hiatus,  malig- 
nant esophageal  stenosis,  or  external  pressure  by  an  aneur}^s- 
mal  sac  or  mediastinal  tumor. 

To  rule  out  these  differential  possibilities  the  Rontgen-ray 
had  best  be  employed  first,  to  disclose  the  presence  of  a  thor- 
acic aneurysm,  mediastinal  growth,  the  presence  of  diverticuli, 
and  the  irregular  outlines  of  a  carcinoma  infiltrating  the  lower 
end  of  the  esophagus  and  causing  a  stenosis.  After  eneur\^sm 
and  m.ediastinal  tumor  have  been  eliminated,  it  is  safe  to  pro- 
ceed with  further  instrumentation.  If  either  a  diverticulum,  a 
kinking  of  the  hiatus  esophagei,  or  a  carcinomatous  stenosis  is 


CARDIOSPASM.  815 

suggested  by  the  Rontgen-ray  examination,  it  is  best  to  make 
use  of  the  esophageal  bougie  devised  by  Pkunmer,  which  consists 
of  a  series  of  oHve  tips,  which  are  attached  to  a  stout  whale- 
bone staff.  The  olives  are  perforated  from  about  their  middle 
to  the  tip.  Six  yards  (548.64  cm.)  of  thread  are  then  swal- 
lowed by  the  patient,  preferably  half  of  this  length  one  after- 
noon and  the  other  half  the  following  morning,  which  permits 
of  the  thread  passing  well  down  into  the  upper  coils  of  the 
intestines  and  becoming  fixed  so  firmly  that  strong  traction 
can  be  made  on  the  proximal  end  emerging  from  the  mouth. 
The  olive  tip  is  then  passed  over  this  thread,  and  by  means 
of  traction  on  the  thread  the  olive  tip  can  be  safely  guided 
through  the  cardia.  By  varying  the  amount  of  traction  the 
sound  can  be  introduced  into  a  diverticulum,  and  its  depth  and 
size  determined. 

The  diagnosis  of  cardiospasm  likewise  may  be  confirmed 
by  a  test  w^hich  I  believe  has  hitherto  not  been  reported, 
namely,  by  esophageal  lavage.  With  the  tip  of  the  stomach- 
tube  in  the  esophagus,  at  a  point  just  above  the  obstruction, 
water  is  allow^ed  to  run  in  from  a  graduated  glass  tank.  It 
will  be  seen  to  run  much  more  slowly  than  if  the  tube  were 
in  the  stomach.  From  100  to  500  mils,  (27fo  to  1  pt.),  accord- 
ing to  the  amount  of  esophageal  dilatation,  v^ill  run  in  slowly, 
but  evenly,  until  the  flow  suddenly  stops,  and  the  level  of  the 
fluid  in  the  graduated  glass  tank  begins  to  oscillate  slightly. 
At  this  point  the  water  is  allowed  to  escape  through  the  out- 
flow tube,  and  without  changing  the  position  of  the  stomach- 
tube  it  will  be  seen  that  the  amount  recovered  is  equal  to  the 
amount  introduced.  When  the  capacity  of  the  esophagus  has 
been  reached,  if  instead  of  opening  the  outflow  tube  the  fluid 
is  allowed  to  remain  in  the  esophagus,  by  its  weight,  assisted 
by  gravity,  it  will  cause  the  cardiospasm  to  relax.  This  will 
occur  in  a  varying  number  of  seconds,  according  to  the  degree 
of  the  spasm,  and  will  permit  some  of  the  water  in  the  esoph- 
agus to  pass  into  the  stomach,  thereby  allowing  an  additional 
flow  from  the  glass  tank,  which  will  then  usually  proceed  in 
a  uniform  way  until  recovered  by  introducing  the  tube  farther 
into  the  stomach.  While  for  purposes  of  demonstration,  this 
last  step  may  be  permissible,  it  is  never  wise  to  distend  the 
esophagus  to  its  point  of  capacity,  as  it  exaggerates  the  al- 


816  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

ready  existing  atony.  The  essential  point  in  diagnosis  by  this 
method  is  the  ability  to  recover  from  the  esophagus  itself  an 
amount  of  fluid  equal,  or  nearly  so,  to  that  introduced.  This 
is  not  possible  in  diverticulitis  or  in  pressure  stenosis  of  the 
cardia. 

It  is  also  of  prime  importance  to  determine  the  presence  of 
a  secondm-y  or  complicating  esophagitis.  This  is  possible  by 
means  of  the  esophagoscope,  but  its  use  is  so  foiTnidable  to 
the  patient  that  the  writer  prefers  to  make  the  diagnosis  by 
the  examination  of  esophageal  sediments  obtained  by  a 
method  published  elsewhere.  It  is  necessary  to  determine 
the  extent  and  kind  of  this  complicating  esophagitis  because  it 
indicates  the  proper  application  of  the  principles  of  treatment, 
for  as  long  as  the  inflammatory  condition  exists  so  long  zmll  the 
cardiospasm  persist,  notwithstanding  efforts  directed  toward 
the  latter  to  the  neglect  of  the  former. 

Properly  treated  patients  do  well,  except  possibly  those 
instances  of  cardiospasm  secondary  to  an  esophagitis  caused 
by  the  action  of  corrosive  poison,  which  heal  with  difficulty, 
and  result  in  contractions  due  to  scar  tissue,  which,  though 
healed,  may  still  predispose  to  spasm. 

TREATMENT. 

In  the  earlier  cases  of  cardiospasm  of  the  primary  type, 
relief  usually  may  be  obtained  by  the  administration  of  anti- 
spasmodics, such  as  belladonna  and  atropin,  pushed  to  the 
limit  of  tolerance  and  with  due  regard  to  a  possible  neurotic 
etiologic  factor.  The  regulation  of  proper  hygiene,  and  the 
use  of  hydrotherapy  and  exercise,  preferably  in  the  open  air, 
should  be  advocated.  If  these  measures  do  not  suffice,  esopha- 
geal bougies  may  be  used,  or  the  spastic  cardiac  ring  may  be 
dilated  by  means  of  dilators  of  the  types  suggested  by  Plum- 
mer  and  Bassler.  When  there  is  a  concomitant  esophagitis, 
measures  should  be  adopted  toward  allaying  this  before  pro- 
ceeding to  the  treatment  of  the  cardiospasm.  Suitable  meas- 
ures are  the  lavaging  of  the  esophagus  with  medicated  solu- 
tions, best  determined  and  controlled  by  the  character  of  the 
esophageal  sediment.  If  the  esophageal  erosion  or  ulceration 
has  become  secondarily  invaded  by  bacteria,  one  can  use  ger- 
micidal  solutions,    such    as   potassium   permanganate,    silver 


CARDIOSPy\SM.  817 

nitrate,  argyrol,  etc.,  until  the  bacteria  have  disappeared  from 
the  inrtammatory  desquamation,  when  blander  solutions,  such 
as  boric  acid  or  normal  salt  solution,  are  to  be  substituted. 
The  use  of  an  autogenous  vaccine  prepared  from  cultures  grown 
from  the  esophageal  sediments  will  facilitate  recovery  from 
the  severer  types  of  esophagitis.  If  the  inflammation  is 
sharply  localized  in  the  form  of  ulcerations  or  erosions,  healing 
medicaments  may  be  directly  applied  by  means  of  long  appli- 
cators introduced  through  a  small  bore  esophagoscope  or 
through  a  rubber  tube  just  long  enough  to  reach  the  incisor 
teeth  to  the  lower  end  of  the  gullet.  When  the  condition  has 
progressed  to  the  stage  of  esophageal  dilatation  and  atoriy,  the 
use  of  intra-esophageal  electricity  is  indicated,  preferably  with 
the  sinusoidal  current  or  the  faradic  current,  by  means  of  a 
suitable  intragastric  electrode.  The  negative  pole  should  be 
attached  to  the  electrode  within  the  esophagus,  and  the  posi- 
tive pole  to  the  external  electrode  in  the  form  of  a  hand 
sponge,  which  is  to  be  carried  over  the  transverse  processes 
from  the  seventh  cervical  to  the  third  thoracic  vertebra,  and 
over  the  sternomastoid  muscles,  particularly  the  left,  to  stimu- 
late the  vagus.  Before  turning  on  the  current  the  patient 
should  drink  a  small  glassful  of  water  to  serve  as  a  better  con- 
ductor of  electricity  and  to  prevent  burning  by  direct  contact. 
The  duration  of  each  treatment  should  not  exceed  ten  minutes, 
and  should  be  given  daily  in  severe  cases  until  improvement  is 
noted.  In  those  cases  showing  progressive  loss  of  weight,  due 
to  inanition,  it  is  important  to  arrange  the  diet  in  the  form  of 
liquids,  the  total  caloric  value  of  which  for  twenty-four  hours 
should  be  over  3000.  This  can  be  accomplished  by  the  liberal 
use  of  milk  and  cream,  olive  oil,  butter,  eg'g-nog,  soft-boiled  or 
raw  eggs,  and  non-stimulating  broths. 

In  the  very  late  cases  that  come  under  observation  during 
the  extreme  stage  of  starvation  asthenia,  it  is  perhaps  better 
f,o  do  a  preliminary  gastrostomy,  and  to  feed  directly  through 
the  stomach,  thus  trying  to  build  up  the  strength  of  the  patient 
before  proceeding  to  the  other  treatments.  Apropos  of  oper- 
ative procedure,  Bassler  (loc.  cit.)  suggests,  "that  in  intract- 
able cases  the  approach  to  the  site  and  cause  of  the  stricture 
had  best  be  made  by  the  safer  abdominal  route  rather  than 
through  the  thorax,  and  that  an  operation  which  has  to  do 

52 


818  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

with  the  division  of  the  crura,  either  at  their  insertions  or  the 
bisection  of  two  of  the  inner  portions  of  both  at  the  back  of 
the  gullet  or  some  point  in  the  esophageal  opening  is  worthy 
of  consideration." 

It  is  necessary  to  obsen^e  certain  patients  over  a  long 
period  of  time.  Relapses  from  primary  cardiospasm,  properly 
treated,  are  comparatively  uncommon,  but  relapses  due  to  ex- 
acerbations in  any  residual  esophagitis  are  more  frequent. 

GASTRECTASIS. 

Gastrectasis  is  an  enlargement  of  the  stomach,  coincident 
to,  or  associated  with  a  diminution  of  its  motor  expulsive 
power  which  may  be  either  relative  or  absolute.  The  motor 
defect  must  be  present  if  one  is  to  difi'erentiate  these  cases 
from  megalogastria,  in  which  the  size  of  the  stomach  is  ab- 
normally enlarged,  but  in  which  the  motor  function  remains 
efficient.  In  gastrectasis  the  motor  insufficiency  ma}^  be  abso- 
lute in  the  sense  that  the  muscular  power  of  the  gastric  wall 
has  depreciated  to  the  extent  that  gastric  contents  cannot  be 
propelled  into  the  duodenum  within  normal  time  limits,  or  it 
may  be  relative,  as  in  those  cases  in  which  there  is  p^doric 
obstruction,  and  in  which  the  gastric  musculature,  although 
hypertonic,  is  nevertheless  unable  to  overcome  the  obstruction. 

Gastrectasis  may  occur  in  both  an  acute  and  chronic  form, 
the  latter  being  probabh^  quite  as  common  as  the  former  is 
rare. 

Gastrectasis  is  most  easily  differentiated  from  pyloric  ob- 
struction, especial!}'  in  the  chronic  form,  by  the  fact  that  while 
there  is  marked  motor  delay  during  the  digestive  .periods,  the 
stomach  is  able  to  empty  itself  completely  overnight.  This  is 
the  rule,  although  occasionally  in  the  more  severe  forms  the 
fasting  morning  stomach  shoAvs  overnight  retention. 

The  Acute  Form  of  Gastrectasis  (acute  dilatation  of  the 
stomach).  Brinton  is  accredited  with  the  first  description  of 
this  condition,  more  than  sixty  years  ago,  but  it  remained  for 
Fagge,  twenty  years  later,  accurately  to  describe  its  clinical 
features.  Since  then  over  300  cases  have  been  reported  in  the 
literature ;  but  its  frequency  is  far  greater  than  this,  if  one  con- 
siders the  large  number  of  unpublished  cases.     While  it  is  a 


GASTRECTyVSJS.  819 

distinctly  unusual  condition  from  a  comparative  standpoint, 
doubtless  many  cases,  especially  those  of  mild  degree,  have 
escaped  recognition. 

Form  1.  Dilatation  of  the  stomach. 

Form  2.  Dilatation  of  the  stomach  and  first  portion  of  the 
duodenum. 

Form  3.  Dilatation  of  the  stomach,  the  entire  duodenum 
and  occasionally  the  jejunum. 

The  known  etiologic  factors  are  somewhat  varied,  but  most 
of  them  can  be  combined  under  the  heading  of  an  acute  tox- 
emia, which  may  locally  cause  a  paresis  of  the  gastric  muscu- 
lature, or  may  paralyze  the  motor  fibers'  of  the  vagi  and  the 
cervical  sympathetica  supplying  the  stomach.  This  toxemia 
may  arise  during  the  course  of  acute  infections,  prominent 
among  which  may  be  mentioned  typhoid  fever,  pneumonia, 
miliary  tuberculosis,  and  occasionally  cardiorenal  disease. 
More  common  than  these  are  sudden  toxemias  of  still  obscure 
causation  occurring  as  post-operative  manifestations,  espe- 
cially following  operations  upon  the  stomach  and  mid-gut, 
although  quite  frequently  it  has  been  noted  in  operations 
involving  the  lower  abdominal  zones.  A  contributing  factor 
to  such  toxemias  are  the  post-narcotic  effects  of  prolonged 
ether  or  chloroform  anesthesias. 

Mechanically,  gastrectasis  can  be  produced  by  an  acute 
traction  upon  the  duodenum,  by  angulation  of  the  duodenum 
by  the  mesenteric  vessels  (mesenteric  ileus)  ;  by  deformities 
of  the  spine  acting  similarly  and  perhaps  also  interfering  with 
the  motor  fibers  of  the  peripheral  portion  of  the  vagus ;  or  by 
displaced  abdominal  neig'hborhood  viscera.  Again  certain 
cases  have  been  noted  after  traumatic  injuries  to  the  head  in 
which  the  motor  nerves  have  been  supposedly  injured.  Acute 
dilatation  confined  to  the  stomach  alone  can  be  caused  bv 
simultaneous  spasm  of  the  pylorus  and  cardia  with  a  sudden 
increase  in  intragastric  tension.  Those  cases  in  which  the 
dilatation  involves  the  segment  of  the  gut  below  the  duo- 
denum, are  necessarily  very  severe  and  may  predispose  readily 
to  a  fatal  issue. 

Again,  dietetic  errors  {e.g.,  gastric  dilatation  following  the 
ingestion  of  foods  that  have  rapidly  undergone  fermentation 
of  high  degree)  have  been  occasionally  reported  as  etiologic 


820  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

factors.     If  so,  they  are  far  less  common  than  those  mentioned 
above. 

In  the  course  of  acute  infectious  diseases,  usually  at  their 
toxemic  height,  or  within  a  few  days  after  operation  or  pro- 
longed anesthesia,  the  symptoms  may  be  ushered  in  with  acute 
epigastric  pain  which  may  be  somewhat  localized  to  the  right 
of,  or  at,  the  median  line  in  the  neighborhood  of  the  pylorus 
or  duodenum-  This  is  rapidl}^  followed  by  profuse  and  con- 
tinuous vomiting.  Symptoms  of  shock  may  rapidly  appear  or 
may  be  delayed  for  a  few  hours.  Unless  obser\^ed  carefully 
the  initial  period  of  shock  may  he  overlooked.  Indeed,  the 
symptoms  may  be  so  closely  allied  to  those  of  an  acute  intes- 
tinal obstruction,  or  to  an  acute  perforated  viscus,  that  close 
observation  and  rapid  differential  diagnosis  must  be  applied 
to  prevent  primary  operative  interference.  In  some  cases  the 
condition  is  not  ushered  in  with  acute  pain,  but  instead  a 
gradually  developing  epigastric  or  left  hj^pochondriac  soreness 
and  a  dull  sense  of  pain  may  be  associated  with  the  other 
symptoms. 

Vomiting  is  most  conspicuous.  If  associated  with  dietetic 
errors  the  first  vomitus  consists  of  the  fermenting  gastric 
chyme,  but  otherv\nse  it  is  likely  to  be  somewhat  grumous 
brownish  material  flecked  with  bile-stained  mucus.  Later  on 
biliar}^  vomiting  of  large  amounts  of  light  or  dark  greenish 
fluid  indicates  duodenal  dilatation  and  pyloric  relaxation. 
AMiere  the  jejunum  is  likewise  involved  a  dilterent  kind  of 
bi'ozi'nish  green  vomitus  is  recovered  which  has  the  character- 
istic odor  of,  and  mav  be  microscopical^  diagnosed  as,  fecal 
vomiting.  The  one  most  characteristic  feature  of  this  vomit- 
ing is  its  excessive  amount  and  its  fluidit}',  which  is  partly  due 
to  a  transudation  from  the  gastric  and  duodenal  mucosa. 
Later  on,  as  retchinsf  continues  occult  bleedino-  can  be  demon- 
strated  in  the  vomitus,  and  later  blood-stained  flecks  of  mucus 
appear. 

In  the  severer  cases  well-marked  gastric  tetany  may  be 
obsen-ed,  and  this  was  a  conspicuous  symptom  of  one  of  the 
writer's  cases  of  acute  dilatation  of  the  stomach,  associated 
with  the  acute  gastric  crises  of  syphilis. 

The  ohjective  findings  are  characteristic,  and  inspection  of 
the  abdomen  usually  discloses  a  visible  and  palpable  tumor 


GASTRECTASIS.  821 

conforming;  to  the  position  of  the  stomach,  whether  normally- 
situated  or  abnormally  displaced.  In  one  patient  it  occupied 
a  vertical  position  as  an  enormous  bologna-shaped  tumor,  with 
the  identical  surface  topography  of  the  descending-  colon.  Ac- 
cording to  whether  the  contents  of  the  stomach  are  gaseous 
or  fluid,  there  will  be  a  widening  of  the  area  of  gastric  tym- 
pany, or  a  widened  area  of  percussion  dullness  replacing  gas- 
tric t^^mpany.  The  knees  are  usually  held  drawn  up  against 
the  abdominal  wall  in  an  effort  to  reflex  the  lower  abdominal 
zones.  Diffuse  epigastric  or  left  hypochondriac  palpatory 
soreness  or  tenderness  can  be  made  out.  If  there  is  peritoneal 
irritation,  muscle  rigidities  may  be  noted.  After  the  condition 
has  been  present  for  a  varying  length  of  time,  usually  a  few 
hours,  the  pinched  features  of  the  patient  rapidly  assume  the 
Hippocratic  facies,  and  the  objective  evidence  of  circulatory 
shock  may  be  marked. 

In  the  severe  cases  no  difficulty  is  encountered  in  making 
the  diagnosis.  It  is  in  the  lesser  grades  that  a  keen  observation 
and  interpretation  of  the  symptoms  must  be  developed.  In 
any  case  in  which  vomiting  of  the  type  described  occurs  in  the 
course  of  an  acute  infection,  or  is  prolonged  beyond  the  first 
few  hours  after  operation  or  anaesthesia,  the  suspicion  of  this 
condition  may  be  strongly  entertained.  It  is  signally  import- 
ant that  the  differential  diag'nosis  of  this  condition  should  be 
separated  from  acute  intestinal  obstruction,  volvulus,  intus- 
suception,  and  acute  arterio-mesenteric  ileus,  which  may  secon- 
darily produce  acute  dilatation  of  the  stomach.  Indeed,  it  is 
only  the  results  of  the  first  few  hours  of  energetic  treatment 
that  in  some  cases  serves  to  make  this  differential  diagnosis. 

The  prognosis  of  gastrectasis,  whether  moderate  or  severe, 
is  serious,  and  in  the  latter  is  essentially  grave,  and  will  de- 
pend largely  upon  the  early  recog'nition  of  the  condition,  and 
the  energetic  skill  with  which  it  is  treated. 

TREATMENT. 

In  all  cases  whether  primarily  produced  by  fractional  pres- 
sure on  the  duodenum,  as  in  mesenteric  ileus,  or  secondarily 
caused  by  the  weight  of  the  fluid  contents  sagging  down  a 
paretic  gastric  wall,  thereby  causing  pyloric  or  duodenal  kink- 
ing, the  first  essential  therapeutic  requirement  is  the  adoption 


822  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

of  the  proper  postural  attitude,  to  assist  in  the  prompt  mechan- 
ical emptying  of  the  stomach.  To  this  end  the  foot  of  the  bed 
should  be  elevated  from  12  to  20  inches  (30.4  to  50.8  cm.),  and 
the  patient  turned  from  the  dorsal  position,  or,  if  his  strength 
permits,  placed  in  the  knee-chest  position.  Assisted  by  atten- 
dants, after  this  position  has  been  maintained  for  a  short  time, 
he  should  be  placed  in  the  right  or  left  antero-lateral  abdom- 
inal position,  AVhich  of  these  two  positions  best  mechanically 
fulfills  its  purpose  possibly  cannot  be  told  until  both  have  been 
tried  in  the  individual  case.  As  a  general  rule,  the  left  antero- 
lateral abdominal  position  allows  the  weight  of  the  fluid-filled 
stomach  to  fall  away  from  the  duodenum  and  to  straighten 
out  any  kink  at  this  point.  Again,  this  position  has  been  fluoro- 
scopically  determined  as  best  suited  to  the  rapid  emptying  of 
the  stomach. 

To  be  placed  in  this  position  the  patient  should  be 
turned  on  his  ventral  surface,  with  the  head  to  the  left  and 
slightly  overhanging  the  side  of  the  bed.  The  weight  should 
be  placed  on  the  left  antero-lateral  aspect,  the  right  arm  being 
curled  under  the  head  or  stretched  out  across  the  bed,  while 
the  left  arm  may  be  allowed  to  hang  down,  supported  by  a 
chair,  or  it  may  be  placed  parallel  to  the  left  side  of  the  body. 
To  aid  in  throwing  the  weight  on  the  left  side,  the  right  half 
of  the  body  is  supported  by  a  series  of  low  pillows,  from  neck 
to  heels.  In  some  cases  it  is  of  assistance  to  place  a  small 
bolster-type  pillow  under  the  abdomen  at  about  the  level  of 
the  navel.  Such  a  pillow  should  measure  from  12  to  16  inches 
(30.4  to  40.6  cm.)  long  and  6  to  8  inches  (15.2  to  20.3  cm.)  in 
diameter,  and  is  readily  constructed  from  a  pound  roll  of  ab- 
sorbent cotton  wrapped  in  a  bath  towel  and  fastened  with  ad- 
hesive tape. 

The  next  essential  point  of  treatment  is  prompt  lavage, 
which  should  be  thorough,  frequently  repeated,  or,  indeed, 
made  continuous.  The  writer  recommends  the  following  pro- 
cedure : 

After  thoroughly  washing  out  the  stomach  with  a  large 
sized  stomach-tube  (32  to  34  F.),  it  is  withdrawn  and  re- 
placed by  the  smaller  calibrated  duodenal  tube,  introduced 
either  through  the  mouth  or  through  the  nares,  and,  after 
reaching  its  proper  level  in  the  stomach,   strapped  securely 


GASTRECTASIS.  823 

to  the  patient's  cheek  by  adhesive  plaster.  To  avoid  traction 
upon  the  nostrils  or  pharynx,  the  tube  should  be  firmly  fast- 
ened by  passing  it  through  a  safety-pin  pinned  to  the  pillow 
or  mattress  at  a  point  6  to  8  inches  (15.2  to  20.3  cm.)  from 
the  patient's  face.  The  proximal  end  of  the  duodenal  tube 
is  attached  to  one  of  the.  horizontal  arms  of  a  small  calibrated 
glass  T-tube,  to  the  other  horizontal  end  of  which  is  attached 
rubber  tubing  running  to  an  outflow  pail,  and  the  vertical 
end  of  the  T-tube  is  attached  by  means  of  rubber  tubing  to 
an  irrigating  tank  of  1  or  2  liters  (quarts)  capacity  sus- 
pended 2  to  3  feet  (60.8  to  91.2  cm.)  above  the  patient's 
head.  A  pressure  clamp  should  be  placed  over  the  rubber 
tubing  between  the  irrigating  tank  and  the  T-tube,  and  a 
second  one  between  the  T-tube  and  the  outflow  pail.  By 
alternately  releasing  pressure  upon  the  tube  from  the  irrigat- 
ing tank  and  that  running  to  the  outflow  pail,  the  patient's 
stomach  can  be  continuously  and  gently  lavaged  and  aspirated 
by  siphonage. 

The  lavaging  fluid  should  be  warmed  to  the  body  heat,  and 
should  consist  of  plain  water,  %o  normal  solution  of  soda  bi- 
carbonate, or  normal  salt  solution.  The  writer  has  likewise 
found  a  1  to  3  solution  of  alkalol  useful  on  account  of  its  bland 
alkalinity,  and  it  may  either  be  introduced  through  the  irrigat- 
ing tank  or  directly  into  the  duodenal  tube  by  means  of  a  2- 
or  3-ounce  Triumph  syringe.  The  writer  cannot  emphasize 
too  strongly  the  value  of  this  continuous  method  of  lavage. 
The  small  tube  is  readily  tolerated  by  the  patient,  and  over- 
comes the  objection  of  the  frequent  introduction  and  removal 
of  the  large-sized  stomach-tube. 

Where  hypersecretion  is  evident  in  such  cases,  especially 
if  associated  with  pylorospasm,  the  hypodermatic  use  of 
atropin  sulphate  in  repeated  doses  of  %oo  to  %oo  of  a-  grain 
(0.0003  to  0.0002  Gm.)  will  be  of  material  advantage.  If  there 
is  marked  gastric  hyperesthesia,  1  or  2  ounces  (30  to  60  mils) 
of  olive  oil  containing  2  to  3  per  cent,  of  anesthesin  may  be  in- 
troduced through  the  duodenal  tube,  or  5  to  10  grains  (0.3  to 
0.6  Gm.)  of  chloretone,  dissolved  in  2  or  3  ounces  (60  or  90 
mils)  of  water,  may  be  similarly  introduced.  The  patient  mav 
be  allowed  to  suck  cracked  ice,  although  none  should  be  swal- 
lowed.    If  there  is  pronounced  nausea,  2  to  3  drams  (7.5  to 


§24  DISEASES    OF   THE   DIGESTIVE    SYSTEM. 

11.2  mils)  of  brandy  or  crane  de  mcnthe  may  be  added  to  the 
cracked  ice.  The  writer  has  lost  confidence  in  the  efficiency 
of  cerium  oxalate  in  controlling  nausea  or  vomiting.  It  is 
essential  that  all  foods  should  be  withheld  by  mouth  until  all 
nausea  has  ceased  and  the  stomach  has  become  definitely  re- 
tentive, and  when  feeding  is  resumed  the  dietary  should  con- 
form to  the  general  plan  of  the  ulcer  cure.  In  the  meantime 
nourishment  is  to  be  supplied  by  rectal  enemata  and  by  the 
use  of  proctoclysis  with  a  %o  normal  soda  bicarbonate  solu- 
tion, to  which  may  be  added  5  per  cent,  of  glucose,  to  assist 
in  overcoming  a  starvation  acidosis. 

The  mouth  may  be  swabbed  out  with  a  mixture  of  1  ounce 
(30  mils)  of  glycerin  mixed  with  the  juice  of  one  lemon  or  one 
orange,  or  with  orange  albumin.  Supportive  measures  should 
be  carried  out  to  combat  collapse  by  the  use  of  hot  water  bot- 
tles or  electric  pad  warmers,  until  secondary  pyrexia  has  oc- 
curred, when  ice  or(cool  sponges  will  be  grateful  to  the  patient. 
Strict  attention  to  nursing  details  are  quite  as  essential  to  re- 
covery as  is  the  direct  medical  care. 

Where  the  above  measures  do  not  result  in  favorable  im- 
provement, the  writer  wishes  to  particularly  emphasize  a 
method  that  has  served  well  in  5  cases  within  his  personal 
knowledge.  It  is  a  mechanical  maneuver^^  a.nd  consists  of 
making  of  pressure  by  means  of  a  bi-forked  metal  pressor  in- 
strument (devised  by  Abrams)  over  segmental  areas  of  the 
spinal  sympathetic  nervous  system.  For  the  relief  of  acute 
dilatation  of  the  stomach,  a  firm  degree  of  pressure  should  be 
exerted  for  from  thirty  to  sixty  seconds  with  the  pressor  in- 
strument placed  across  the  spinal  column  in  the  interspaces 
between  the  third  and  fifth  thoracic  vertebras.  Within  a  cer- 
tain number  of  seconds  explosive  eructations  of  gas  occur,  or 
a  sudden  rush  of  gaseous  or  fluid  contents  can  be  heard,  pass- 
ing ostensibly  through  the  pylorus  or  duodenum  and  into  the 
jejunum,  with  prompt  disappearance  of  the  gastric  tumor. 
In  some  cases  this  maneuver  must  be  repeated  every  fifteen 
or  twenty  minutes  for  one  or  two  hours  before  the  condition 
is  permanently  under  control.  Abram's  method  of  spondylo- 
therapy  should  b3^  no  means  be  urged  to  supplant  the  other 
methods  of  treatment  outlined  above-,  and,  indeed,  possibly  it 
should  not  be  resorted  to,  in  the  light  of  our  present  knowl- 
edge, until  all  other  measures  have  been  exhausted. 


GASTRECTASIS.  825 

As  to  just  what  interpretation  can  be  made  of  the  startHng 
results  of  this  procedure,  a  final  answer  cannot  at  present  be 
given.  The  writer  is  not  prepared  to  accept  Abram's'*^  ex- 
planation of  this  so-called  "stomach  contraction  reflex,"  but 
would  like  to  suggest  the  following  hypothesis  as  a  plausible 
explanation  of  the  effectiveness  of  this  treatment :  The  simul- 
taneous cardio-  and  pylorospasm  may  be  the  result  of  a  lawless 
or  over-stimulated  vagus  (a  vagotony),  which  the  inhibitory 
action  of  the  thoracic  sympathetic  fibers  to  the  stomach  is 
powerless  to  overcome  until  mechanically  stimulated  by  forced 
pressure.  It  is  probable  that  the  true  explanation  will  be 
lifted  from  the  veil  of  obscurity  when  our  knowledge  of  the 
states  of  vago-  and  sympathetico-tony  and  atony  is  more 
complete.  Nevertheless,  the  writer  is  prepared  to  say  that 
this  method  has  proved  successful  in  some  cases  where  all 
other  methods  had  failed.  Abrams  also  claims  that  a  con- 
traction reflex  of  the  stomach  can  be  obtained  by  strong  per- 
cussion over  the  transverse  spines  of  the  first,  second,  and 
third  lumbar  vertebrae. 

To  the  writer  this  maneuver  certainly  appears  worthy  of 
a  careful  trial,  although  it  should  not  supplant  other  therapeu- 
tic measures.  It  does  not  seem  capable  of  doing  lasting  harm, 
and  may  give  such  unexpectedly  brilliant  results  as  will  war- 
rant its  use. 

Among  other  medicinal  agents  that  may  be  employed,  may 
be  mentioned  the  use  of  eserin  sulphate  in  a  dosage  of  Y^q  to 
YiQQ  of  a  grain  (0.0013  to  0.0006  Gm.),  in  combination  with 
Yso  of  a  grain  (0.00216  Gm.)  of  strychnin,  which  may  be 
repeated  every  three  or  four  hours  until  intestinal  peristalsis 
is  excited. 

For  the  relief  of  tympanites,  when  results  cannot  be  ob- 
tained by  simple  enemas  followed  by  colonic  irrigation,  an 
alum  enema  may  be  substituted,  using  1  ounce  (30  Gms.)  of 
powdered  alum  to  a  pint  (500  mils)  of  water.  If  this  does 
not  serve  to  empty  the  bowels  and  relieve  tympanites,  elaterin 
may  be  given  by  hypodermic  injections  in  a  dosage  of  ^  to  ^ 
grain  (0.016  to  0.032  Gm.),  reinforced  by  Yso  of  a  grain 
(0.00216  Gm.)  of  strychnin  to  overcome  the  depressing  action 
of  the  elaterin.  Both  elaterin  and  eserin  should  be  used  cau- 
tiously, and  never  if  the  patient  is  in  a  state  of  exhaustion. 


826  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

Other  medicinal  agents  are  not  indicated,  except  in  the  way 
of  supportive  expectant  management. 

If  these  measures  fail,  but  little  hope  can  be  entertained 
from  surgical  interference.  In  former  years  gastrojejunos- 
tomy was  frequently  practised,  but  the  results  were  not  favor- 
able. In  cases  due  to  a  kinking  of  the  duodenum  from  ad- 
hesions, or  in  those  with  evidence  of  intestinal  obstruction 
lower  down,  exploratory  laporatomy  may  be  justifiable,  but 
to  be  of  any  use  it  must  be  undertaken  promptly. 

GASTRIC    CRISES    OF    CEREBROSPINAL 
SYPHILIS. 

Spinal  or  cerebrospinal  S3'philis  is  comparatively  common, 
and  its  incidence  has  been  considerably  widened  since  the 
demonstration  of  the  Treponema  pallidum  in  the  meninges  and 
in  the  nerve  tissues  of  the  spinal  cord  and  brain. 

In  most  cases  the  infection  of  the  nervous  system  takes 
place  during  the  late  primary  and  early  secondary  periods, 
and  thus  may  potentially  afTect  the  nervous  system  in  all 
cases.  That  all  cases  are  not  so  infected  warrants  the  belief 
that  there  are  various  strains  of  the  treponema,  each  pos- 
sessing selective  affinity  for  certain  tissues.  A  racial  immun- 
ity is  likewise  suggested  if  we  consider  the  rarity  of  tabes 
dorsalis  in  the  Chinese  and  the  negro,  both  of  which  races  are 
conspicuously  saturated  with  syphilis. 

In  tabes  dorsalis  it  is  more  than  of  passing  interest  that 
the  history  frequently  shows  an  inconspicuous  or  atypical 
primary  lesion,  and  the  absence  or  mildness  of  secondary 
symptoms  and  lesions.  This  might  mean  either  an  infec- 
tion with  a  strain  of  treponema  having  an  affinity  only  for 
the  nervous  system,  and  an  inability  to  colonize  in  other  vis- 
cera or  body  tissues,  or  it  might  mean  that  the  very  mildness 
of  the  primary  and  secondary  lesions  may  have  caused  the 
individual  so  infected  little  recognition  of  the  seriousness  of 
his  disease,  so  that  its  treatment  is  relatively  or  absolutely 
neglected,  until  the  onset  of  cerebrospinal  symptoms. 

Among  the  most  interesting  and  important  of  these  early 
symptoms  of  cerebrospinal  syphilis  are  the  visceral  crises, 
which  generally  make  their  appearance  in  the  preataxic  stage. 


.  GASTRIC    CRISES    OF    CEREBRUSIMNAL    SVriiiLlS.        827 

These  visceral  crises  may  be  laryngeal,  bronchial,  cardiac,  gas- 
tric, intestinal,  renal,  rectal,  and  genital. 

It  is  the  purpose  here,  however,  to  discuss  briefly  the 
symptoms,  diagnosis,  and  treatment  of  the  gastric  crises. 

The  symptoms  of  gastric  crises  consist  of  sudden  seizures 
3f  upper  abdomirial  pain,  preceded,  accompanied,  or  followed 
by  vomiting,  and  associated  with  various  disturbances  of 
secretion.  These  attacks  usually  occur  with  extraordinary 
suddenness,  may  strike  down  the  individual  while  in  apparent 
2;"Ood  health,  and  frequently  with  no  premonitory  symptoms. 
The  crisis  may  last  for  several  days,  occasionally  for  two 
weeks  or  more,  and  usually  ceases  as  spontaneously  as  it 
Dccurred,  with  a  sudden  restoration  to  the  patient's  normal 
state  of  health,  despite  the  severity  of  the  attack. 

Historically,  several  authorities,  Graves,  Romberg,  Grube, 
and  Delamarre  reported  cases  exhibiting  this  symptom- 
complex  which  antedated  Charcot's  publications  of  1868 
and  the  years  following,  but  by  universal  consent  to  Charcot 
is  given  the  credit  for  his  masterly  presentation  of  the  symp- 
toms and  pathology  of  the  gastric  crises  occurring  in  tabes 
dorsalis,  for  which  clinical  picture  he  coined  the  term  "crises 
gastrique." 

For  a  few  years  there  ensued  diagnostic  confusion,  re- 
sulting in  published  reports  of  visceral  colics  with  nausea, 
vomiting,  hemorrhages,  diarrhea,  etc.,  but  associated  with 
various  purpuric  skin  lesions  or  edemas,  which  would  place 
them  among  the  group  of  visceral  crises  occurring  in  angio- 
neurotic edemas  and  erythemas. 

Sainton  and  Trenck  have  described  in  great  detail  six 
different  varieties  of  gastric  crises.  Suffice  it  to  say  that 
there  may  be  attacks  exhibiting  a  great  variety  of  symptoms, 
varying  both  as  to  duration,  frequency  and  severity.  There 
may  be  mild  attacks  featured  only  by  vomiting,  with  absence 
of  pain  and  absence  of  secretory  disturbances.  There  may  be 
attacks  of  great  severity,  with  agonizing  pain  and  persistent 
vomiting,  first  of  gastric  contents,  later  duodenal  contents, 
and  still  later  jejunal  contents. 

The  greatest  characteristic  of  any  attack,  no  matter  of  zvhat 
variety,  is  the  startling  suddenness  ivith  zuhich  it  is  ushered  in, 
and  its  equally  abrupt  termination.     Even  after  a  severe  and 


828  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

protracted  crisis  of  a  week  or  longer,  when  it  is  over  the  pa- 
tient becomes  immediately  hmigry,  wishes  to  eat,  and  unless 
his  case  be  complicated  by  organic  gastric  disease,  for  in- 
stance, such  as  ulcer,  the  stomach  ceases  to  be  irritable,  and 
does  not  occasion  any  digestive  disturbances. 

During  a  severe  attack,  where  pain  is  conspicuous,  it  may 
be  agonizing,  and  cause  the  patient  to  assume  all  sorts  of 
bizarre  positions  to  gain  relief.  While  an  attack  is  in  progress 
the  abdomen  is  usually  retracted,  except  in  those  cases  com- 
plicated by  gastric  or  duodenal  dilatation;  is  often  extremely 
tender  to  palpation,  especially  in  the  epigastrium;  the  muscles 
are  often  held  rigid,  and  if  difficult  vomiting  has  been  persist- 
ent, the  thoracic  and  abdominal  muscles  maintain  a  soreness 
which  may  last  for  several  days  after  the  attack  has  subsided. 
In  the  severe  attacks  the  amount  of  prostration  may  be 
very-v  great,  partl}^  due  to  continual  retching  in  the  vomiting 
types  associated  with  acute  gastric  dilatation,  and  partl}^  due 
to  cardiovascular  failure,  which  may  imminently  threaten  a 
fatal  collapse.  Probably  some  cases  of  this  latter  type  are 
due  to  direct  spirochetal  colonization  in  the  heart  muscle. 

In  another  case  the  premonitory  symptom  was  of  another 
t3'pe.  For  several  days  before  the  attack  there  was  noted  a 
striking  increase  in  the  amount  of  bile-stained  fluid  vomited 
each  morning  from  the  fasting  stomach.  If  this  fluid  could  be 
gotten  rid  of  by  vomiting,  the  symptoms  might  be  aborted. 
If  emesis  could  not  be  secured,  even  by  induced  retching,  the 
sensation  of  double-retrosternal  and  epigastric  lump  (to  be 
described)  would  begin,  and  within  a  few  hours  an  attack 
would  be  under  way.  This  observation  led  me  to  emptv  this 
patient's  fasting  stomach  each  morning  by  duodenal  tube, 
until  he  had  learned  to  do  so  himself.  This  measure  has  not 
only  brought  him  the  greatest  amount  of  relief,  but  has  per- 
mitted eight  months  to  elapse  since  his  last  attack. 

As  stated  earlier,  pain,  vomiting,  and  various  disturbances 
of  gastric  secretion  make  up  the  usual  triad  of  this  condition. 
Yet,  there  is  another  group  of  symptoms  to  be  regarded  as  of 
great  importance.  Not  uncommonly  there  is  a  complaint  of 
lower  thoracic  and  upper  abdominal  sense  of  fullness  and 
pressure  seen  early  in  some  attacks,  which  may  progress  to  an 
unbearable  sense   of  a  ball-like   lump  felt  behind  the  lower 


GASTRIC   CRISES    OF   CEREBROSPINAL   SYPHILIS.       829 

third  of  the  sternum,  a  sense  of  a  "fixed  lump"  that  seems  im- 
possible either  to  get  up  or  down,  and  a  sense  of  a  second 
lump,  referred  to  the  right,  mid,  or  left  epigastrium,  along  a 
line  just  above  or  at  the  level  of  the  navel. 

This  sensation  of  lumps  may  suddenly  disappear,  and  the 
epigastric  pressure-fullness  may  be  relieved,  often  only  tem- 
porarily, by  explosive  belching  of  gas,  or  by  the  passing  of 
gas  from  stomach  to  intestines,  or  by  expulsion  of  gas  from 
the  rectum.  This  type  of  crisis  may  be  similar  to  that 
described  by  Fournier  of  the  flatulent  variety  of  gastric  colic, 
in  which,  without  apparent  cause,  there  occur  attacks  of  loud 
eructations  of  odorless  and  tasteless  gases  for  several  days, 
1:)Ut  unaccompanied  by  vomiting. 

Again,  there  is  a  mild  form  of  gastric  crisis,  featured  by 
sudden  easy  and  apparently  causeless  vomiting',  independent 
entirely  of  food-taking,  or  the  character  of  the  food.  This 
vomiting  is  spontaneous,  painless,  may  occur  several  times  a 
day  for  several  days,  and  the  vomitus  may  be  gastric  or 
biliary,  may  be  practically  odorless  and  tasteless,  or  may  be 
sour,  fermentative,,  bitter  or  rancid,  depending  upon  the  state 
of  the  gastric  motility  and  chemistry,  and  yet,  apparently,  is 
not  primarily  dependent  upon  these  as  causative  factors. 

Gastric  crises  appear  in  tabes  with  considerable  frequency ; 
probably  one  out  of  every  third  or  fourth  case  will  present  this 
complication,  and,  in  addition  to  this,  the  gastric  crises  fre- 
quently appear  as  the  initial  symptom  of  tabes.  With  the  his- 
tory of  sudden  onset  and  symptoms  of  acute  abdominal  pain 
associated  with  vomiting,  many  a  tabetic  sufl:"ering  with  gas- 
tric crises  has  been  rushed  to  the  operating  table  for  an  un- 
warranted laparotomy.  The  literature  on  the  subject  is  re- 
plete with  instances  of  this  sort.  Nuzum,  in  his  study  of 
1000  tabetics,  found  that  97  (nearly  1  in  every  10)  had  been 
operated  upon  under  the  mistaken  diagnosis  that  the  gastric 
crises  were  an  expression  of  some  form  of  abdominal  surgical 
disease,  and  yet  nothing  was  found  intra-abdominallv  to 
account  for  the  symptoms.  This  can  be  avoided  by  a  thorougii 
examination  of  the  nervous  system  of  such  patients. 

The  diagnosis  in  a  good  many  cases  is  easy,  and  in  others 
exceedingly  difficult.  If  the  patient  is  observed  in  his  first 
attack  of  gastric  crisis,  and  especially  if  it  presents  tlie  initial 


830  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

symptom  of  a  cerebrospinal  syphilis,  a  positive  diagnosis,  can- 
not be  made  without  a  serologic,  chemical,  and  cystologic 
examination  of  the  spinal  fluid.  Of  course,  one  who  has  seen 
a  sufficient  number  of  such  cases  to  have  had  the  peculiar 
symptomatology  impressed  upon  his  attention  may  correctly 
hazard  a  guess. 

A  carefully  taken  history  will  naturally  throw  much  light 
upon  the  relative  importance  of  the  diagnostic  possibilities 
concerned  in  any  given  case.  If  a  preceding  luetic  infection  is 
admitted,  gastric  crises  should  always  he  considered. 

While  the  usual  trinity  of  symptoms  consists  of  pain, 
vomiting,  and  disturbances  of  gastric  secretion,  they  are  by  no 
means  always  present  in  any  given  case ;  one  or  two  may  be 
lacking,  and  even  if  all  three  are  present  such  symptoms  may 
occur  in  many  other  conditions. 

The  examination  of  the  spinal  fluid  is  the  sine  qua  non. 
In  the  majority  of  cases  of  spinal  syphilis  it  will  show  a 
pleocytosis,  an  excess  of  globulin,  and  a  positive  Wassermann 
reaction.  Until  this  has  been  made,  it  is  often  wiser  to  main- 
tain an  attitude  of  masterful  inactivity,  or  watchful  waiting, 
if  we  would  avoid  the  humiliation  of  an  unjustifiable  explora- 
torj'  laparotomy.  Fordyce  and  others  endorse  the  value  of 
the  Lange  or  colloidal  gold  test  of  the  spinal  fluid  to  dis- 
tinguish true  paresis  from  simulating  types  of  cerebrospinal 
syphilis. 

Where  gastric  crises  do  not  appear  as  the  initial  symptom 
of  spinal  syphilis,  the  diagnosis  is  often  clarified  by  an  ex- 
amination of  the  nerA'ous  system.  Irregularities  in  the  size 
and  outline  of  the  pupils,  or,  still  more  significant,  an  Arg\'ll 
Robertson  pupil;  a  positive  Romberg  sign;  the  absence  of  one 
or  both  knee-jerks  (Westphal's  sign),  or  a  break  in  the  arc 
of  other  of  the  deep  reflexes  (absence  of  the  Achilles  tendon 
reflex,  etc.)  ;  a  thoracic  zone  of  hyperesthesia  or  anesthesia 
will  make  the  examination  of  the  spinal  fluid  yield  largely 
corroborative  testimony.  Transitory  ocular  squint  or  lesions 
of  the  auditor}^  nerve  are  frequenth^  monosymptomatic  fore- 
runners of  tabes,  and  should  receive  more  than  passing 
attention. 

The  prognosis  is  generally  serious,  and  often  extremely 
bad. 


GASTRIC   CRISES    OF   CEREBROSPINAL   SYPHILIS.        831 

TREATMENT. 

The  writers  method  of  treatment  during  acute  attacks  is 
as  follows : 

Absolute  bed-rest ;  elevation  of  the  foot  of  the  bed,  8  to  12 
inches  (20.3  to  30.4  cm.)  to  guard  against  dilatation  of  the 
stomach,  which  is  not  uncommon.  Absolutely  no  food  by 
mouth  is  allowed.  Paraffin  wax  should  be  chewed  every  2 
hours.  The  patient  may  suck  cracked  ice,  to  which  may  be 
added  two  or  three  teaspoonfuls  (7.5  or  11.2  mils)  of  brandy 
or  crime  de  meiithe,  if  there  is  pronounced  nausea.  The  mouth 
may  be  swabbed  out  with  a  mixture  of  1  ounce  (30  mils)  of 
glycerin  and  the  juice  of  one  lemon.  If  vomiting  is  a  feature 
of  the  attack,  the  stomach  should  be  emptied  by  means  of  a 
duodenal  tube  and  syringe  aspiration.  An  analysis  of  the 
aspirated  fluid  to  some  extent  will  determine  the  chemistry 
of  the  lavaging  fluid.  If  such  an  analysis  cannot  be  done  at 
once,  plain  water  is  the  safest  lavaging  fluid.  After  the 
stomach  has  been  gently  washed  with  }4  to  1  liter  (1  pint  to 
1  quart)  of  fluid  by  alternate  syringe  injection  and  aspiration, 
the  tube  is  left  in  situ  at  the  proper  level,  and  securely  strap- 
ped to  the  patient's  chin  or  cheek  by  adhesive  plaster.  The 
proximal  end  of  the  tube  is  attached  to  one  of  the  horizontal 
arms  of  a  small  T-tube,  to  the  other  horizontal  limb  of  which 
is  attached  rubber  tubing  running  to  an  outflow  pail,  and 
the  vertical  end  of  the  T-tube  is  attached  by  means  of  rubber 
tubing  to  an  irrigating  tank  of  1  to  2  liters  (1  to  2  quarts) 
capacity,  suspended  2  or  3  feet  (60.8  or  91.2  cm)  above  the 
patient's  head.  A  pressure  clamp  should  be  placed  over  the 
rubber  tubing  between  the  irrigating  tank  and  the  T-tube,  and 
a  second  one  between  the  T-tube  and  the  outflow  pail.  By 
alternately  releasing  pressure  upon  the  tube  from  the  irrigat- 
ing tank  and  the  tube  running  to  the  outflow  pail,  the  patient's 
stomach  can  be  continuously  and  gently  lavaged  and  aspirated 
by  siphonage.  The  lavaging  fluids  should  be  warmed  to  body 
heat,  and  should  consist  of  plain  water,  1 :  10  normal  solution 
of  soda  bicarbonate,  or  noiTnal  salt  solution  to  which  5  per 
cent,  of  glucose  may  later  be  added,  should  there  be  evidence 
of  acidosis.  The  value  of  this  continuous  method  of  lavage 
cannot  be   emphasized   too   strongly.     As   a^  rule,   it   is   well 


832  DISEASES    OF   THE   DIGESTIVE    SYSTEM. 

tolerated,  usually  controls  the  vomiting,  and  prevents  cardiac 
strain  or  injury  to  the  gastric  mucosa  from  continuous  pain- 
ful retching.  If  there  is  evident  hypersecretion,  hypodermics 
of  atropin  sulphate  may  be  injected  subcutaneously  in  dosage 
of  0.0006  gram  (gr.  /ioo)  every  hour  until  three  doses  have 
been  given,  and  then  every  three  hours;  or  after  one  or  two 
injections  have  been  given  from  30  to  60  minims  (1.9  to  3.7 
mils)  of  the  tincture  of  belladonna  may  be  added  to  each  liter 
(quart)  of  the  irrigating  fluid.  This  will  control  both  the 
hypersecretion  and  relieve  or  prevent  pylorospasm  and  its 
consequent  pain.  If  there  is  marked  gastric  hyperesthesia,  1 
or  2  ounces  (30  to  60  mils)  of  olive  oil  containing  2  to  3  per 
cent,  of  anesthesin  may  be  introduced  through  the  duodenal 
tube,  or  0.3  to  0.6  gram  (5  to  10  gr.)  of  chloretone,  dissolved  in 
60  to  90  c.c.  (2  to  3  ounces)  of  water,  may  be  similarly 
introduced. 

For  the  relief  of  the  double-point  spasm,  and  especi- 
all}'  if  gastric  dilatation  has  taken  place,  the  writer  wishes 
particularly  to  call  attention  to  a  method  which  he  has 
found  useful.  It  is  a  mechanical  maneuver,  and  consists 
of  the  making-  of  pressure  by  means  of  a  bi-forked  pres- 
sor instrument  (devised  by  Abrams)  over  segmented  areas 
of  the  spinal  sympathetic  ner^'ous  system.  For  the  relief 
of  acute  dilatation  of  the  stomach,  if  caused  by  simulta- 
neous double-point  spasm,  with  a  resultant  rise  of  intraseg- 
mental  tension,  a  firm  degree  of  pressure  should  be  exerted 
for  from  30  to  60  seconds,  with  the  pressure  instrument 
placed  across  the  spinal  column  in  the  interspaces  between 
the  third  and  sixth  thoracic  vertebrse.  Within  a  compara- 
tively few  seconds  the  patient  will  begin  to  belch  explosively, 
as  the  cardia  relaxes  first,  or  a  sudden  rush  of  fluid  or 
gaseous  contents  can  be  heard  passing  ostensibty  through 
the  relaxed  pylorus  or  duodenum  into  the  jejunum,  and 
simultaneously  the  sense  of  pressure,  fullness,  and  the  pain- 
ful sensation  of  a  double  fixed  lump  is  relieved.  Should 
there  be  gastric  dilatation,  the  area  of  gastric  tympany  rapidly 
becomes  smaller.  This  maneuver  may  have  to  be  repeated 
several  times  before  a  successful  result  is  obtained. 

If  gastric  dilatation  is  pronounced,  in  addition  to  the  eleva- 
tion of  the  foot  of  the  bed  and  the  other  measures  suggested. 


GASTRIC    CRISES    OF    CEREBROSPINAL    SYPHILIS.        833 

the  patient  should  l)e  placed  in  the  right  lateral  abdominal 
position,  and  a  small  bolster  pillow  should  be  put  just  below 
the  lower  border  of  the  stomach,  to  raise  it  to  a  higher  level, 
and  thus  to  prevent  an  aggravation  of  the  condition  by 
dviodenal  or  mesenteric  kinks  or  angulations. 

These  measures  control  the  nausea,  vomiting,  hypersecre- 
tion, gut-spasm,  gastric  dilatation,  and  to  some  extent  the 
pain.  For  really  severe  pain,  such  as  that  due  to  irritation  of 
the  posterior  dorsal  nerve  roots,  nothing  short  of  morphin 
has  proved  thoroughly  satisfactory.  If  the  pain  is  moderate, 
some'  of  the  drugs  suggested  above  may  control  it. 

The  circulation  should  be  carefully  watched  during  the 
acute  attack,  and  if  the  systolic  blood-pressure  falls  below  the 
pulse-rate  the  patient  is  in  need  of  stimulation. 

Feeding  by  mouth  should  not  be  resumed  until  all  nausea 
has  ceased,  and  the  stomach  becomes  definitely  retentive,  and 
when  begun  the  food  should  be  given  in  liquid  form,  fre- 
quently, in  small  amounts,  and  gradually  increasing,  as  in 
the  ulcer  cure  (q.v.s.). 

In  the  meantime  nourishment  is  to  be  supplied  by  rectal 
enemata  and  by  the  use  of  proctoclysis  with  1 :  10  normal  soda 
bicarbonate  solution,  to  which,  may  be  added  5  pet  cent, 
glucose,  and  if  need  be  2.0  to  4.0  grams  (30  to  60  gr.)  of 
sodium  bromid  to  allay  restlessness  and  nervous  apprehension. 

When  convalescence  is  established,  and  the  patient's  hun- 
ger has  returned,  it  is  wise  to  remember  Rosenheim's  caution 
not  to  overload  the  stomach,  on  account  of  the  danger  of 
producing  motor  errors. 

External  applications  to  the  epigastrium  of  wet  com- 
presses, either  hot  or  cold,  give  variable  pain  relief  in  the  same 
individual ;  sometimes  one  will  help,  sometimes  the  other. 
Other  forms  of  counterirritation,  such  as  the  mustard  plaster 
or  fly-blister,  may  be  tried. 

Cerium  oxalate  has  been  extensively  tried,  both  for  the 
relief  of  pain  and  for  vomiting,  with  varying  endorsements. 
Lockwood  states  that  it  has  been  worthless  in  his  hands. 
Ostankow  reported  good  results  from  its  use,  which  led 
Basch  to  try  it  in  18  cases.  He  gave  it  in  doses  of  0.1  gram 
(1^  gr.)  every  two  to  four  hours  during  the  attack,  and  three 
times  a  day  between  the  attacks,  and  found  that  it  did  not 

53 


834  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

in  any  sense  relieve  the  pain,  but  helped  in  controlling  the 
nausea  and  vomiting.  He  likewise  tried  the  effect  of  anti- 
pyrin,  as  recommended  by  Gowers  and  Zippert,  giving  it 
in  doses  0.25  gram  (4  gr.),  repeated  hourly  for  four  doses, 
and  if  no  symptoms  of  circulatory  depression  occurred  he  in- 
creased the  dose  0.5  gram  or  0.1  gram  (7  to  15  gr.).  He  came 
to  the  conclusion  that  it  acts  as  a  general  sedative,  especially 
in  those  cases  with  pain,  but  had  no  effect  in  controlling 
vomiting. 

Carrying  out  a  suggestion  by  Oppenheim,  Basch  tried 
the  subcutaneous  injection  of  0.002  gram  (%o  g^-)  of  nitrate 
of  strychnin  in  five  cases,  which  showed  no  improvement  after 
either  cerium  oxalate  or  antipyrin,  and  in  two  cases  secured 
relief  from  pain  and  restful  sleep,  but  no  satisfactory  effect  in 
the  other  three. 

Hunt  mentions  the  use  of  injections  of  cocain  into  the 
epidural  and  subarachnoid  spaces  of  the  spinal  canal,  as  sug- 
gested by  Oppenheim,  and  a  similar  use  of  alcohol  and  stovain, 
as  recommended  by  Levy  and  Pope.  He  also  mentions  the 
use  of.  methylene  blue  in  1-grain  capsules. 

Veronal  and  trional  in  combination  in  a  dosage  of  0.15 
gram  (2}4  gr.)  each,  if  given  everj^  two  to  four  hours,  calm 
the  pain,  and  induce  restful  sleep  when  the  attack  is  over. 
Lockwood  also  advocated  larger  doses  of  antipyrin — 1  gram 
(15  gr.) — given  by  the  bowel  every  four  to  six  hours. 

Cannabis  indica  and  belladonna  to  control  hypersecretion, 
and  the  bromids,  chloroform,  cocain,  and  alkaloids  of  opium 
to  control  pain  have  iDeen  tried  with  success  by  Friedenwald 
and  Leitz.  They  also  recommend  the  external  applications  of 
sprays  of  ether  or  ice,  the  .r-ray,  radium  applications  to  the 
epigastrium,  and  the  use  of  the  galvanic  current  with  a  mil- 
liamperage  of  10  to  15,  with  the  negative  pole  applied  to  the 
abdomen,  and  the  positive  pole  over  the  dorsal  vertebrae. 

Finally,  in  most  cases  one  must  have  recourse  to  hypo- 
dermics of  morphin,  which  should  be  used  cautiously  and 
sparingly  on  account  of  the  danger  of  habit  formation,  to 
which  such  sufferers  are  extremely  susceptible ;  and  when 
given  it  should  always  be  under  the  personal  supervision  of  a 
physician. 

The  injection   of  adrenalin   chlorid   in  0.5   mil    (8  m)    of 


GASTRIC   CRISES   OF   CEREBROSPINAL   SYPHILIS.       835 

1 :  1000  solution  should  be  tried,  since  it  is  safe,  and  claimed 
to  be  efficient  in  the  relief  of  ])ain,  and  is,  therefore,  worth  a 
trial  before  morphin.  It  is  well  to  be  familiar  with  the  range 
of  blood-pressure  in  the  individual  case,  and  to  reserve  the 
use  of  adrenalin  for  such  cases  as  exhibit  a  hypertension  dur- 
ing the  attack.  Likewise  the  vasodilators  (sodium  nitrite, 
amyl  nitrite,  etc.)  may  be  tried,  as  recommended  by  Barker 
and  Raymond,  in  those  cases  of  hypertension  in  which  the 
pain  is  contributed  to  by  arteriospasm. 

Intercurrent  Treatment  Between  Attacks.  The  patient 
should  be  brought  to,  and  made  to  maintain,  the  highest  level 
of  health.  His  diet  should  be  simple,  and  made  compatible 
with  his  gastro-intestinal  digestive  chemistry  and  tolerance, 
but  should  be  of  a  high  caloric  value,  containing  an  abundance 
of  fats  and  oils,  in  the  form  of  cream,  butter,  olive  oil,  bone- 
marrow,  codliver  oil,  malt,  cheese,  etc.,  with  a  sufficient 
amount  of  proteins  and  carbohydrates.  It  has  been  truly  sai-d 
that  a  tabetic  who  is  gaining  in  weight  is  doing  well.  The 
meals  should  be  frequent  and  small.  If  during  the  acute  at- 
tack gastric  dilatation  has  occurred,  during  convalescence  and 
for  some  time  thereafter  the  patient  should  lie  down  on  his 
right  side  for  an  hour  after  each  principal  meal,  with  the  foot 
of  the  bed  or  couch  elevated  6  or  8  inches  (15.2  to  20.3  cm). 

Any  state  of  anemia  should  be  combated,  probably  best  by 
intramuscular  injections  of  cacodylate  of  soda  and  citrate  of 
iron  in  a  dosage  of  0.06  gram  (1  gr.)  each,  and  glycerophos- 
phate of  soda  0.15  gram  (2>^  gr.).  These  may  be  given 
every  other  day,  or  Fowler's  or  Donovan's  solution  may  be 
prescribed.    All  act  as  useful  tonics. 

Cardiac  or  vasomotor  irregularities  should  be  corrected. 
When  due  to  an  associated  splanchnoptosia,  proper  abdom- 
inal support  should  be  provided,  the  Curtis  abdominal  pad  for 
men,  and  the  Gossard  corset  for  women,  being  suitable  for 
this  purpose. 

It  is  important  to  mention  the  necessity  of  keeping  the 
bowels  open.  Constipation  is  the  rule,  and  in  some  cases  can 
be  a  real  menance  to  health,  and  actually  provoke  a  gastric 
crisis,  allowing  the  accumulation  and  absorption  of  the  toxic 
Beta  ethylamins,  to  which  Holmes  attaches  great  importance, 
in  initiating  an  attack. 


836  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

The  dietary  should,  therefore,  include  stewed  fruits,  honey, 
treacle,  figs,  dates,  and  whole-wheat  bread.  Liquid  petrolatum 
is  most  efficient.  The  agar  preparations,  impregnated  with 
various  laxatives,  such  as  cascara,  are  useful.  Attention  to 
habit  formation  in  attending  to  the  bowel  movements  should 
be  insisted  upon.  Likewise  the  use  of  proper  abdominal 
exercises. 

When  there  are  special  indications  for  treatment  to  correct 
gastric  symptoms,  whether  organic  or  functional,  these  should 
be  carried  out.  For  example,  in  one  case  the  daily  morning 
removal  of  the  fasting  gastric  residuum  has  done  more  than 
anything  else  to  keep  this  patient  in  comfort,  to  forestall  fur- 
ther critical  attacks,  and  to  build  him  up  to  a  point  where  a 
pyloroplasty  or  gastrojejunostomy  for  pyloric  ulcer  can  be 
performed  with  minimum  risk.  So,  too,  in  a  second  case  an 
operation  for  the  correction  of  an  organic  duodenal  lesion  was 
carried  out  during  the  intercurrent  period,  after  the  patient 
had  been  properly  built  up,  and  the  postoperative  result  has 
been  most  favorable. 

During  this  intercurrent  period  attempts  should  be  made 
to  improve  the  local  nutrition  of  the  spinal  cord.  Counter-irri- 
tation in  the  form  of  dry  cuppings,  the  cautery,  •  galvanism, 
vibratory  massage,  etc.,  may  be  applied  over  the  thoracic  ver- 
tebrae. So,  too,  one  m.ay  find  help  in  the  use  of  the  high-pres- 
sure hose  of  alternating  hot  and  cold  douches  to  the  spine. 
Exercises  designed  to  stretch  the  spinal  cord  have  been  de- 
vised— the  simplest,  and  perhaps  as  efifective  as  any,  being  for 
the  patient  to  lie  flat  on  his  back,  and,  with  heels  on  floor, 
raise  his  body  to  a  sitting  position,  and  conversely  to  keep  his 
head  on  the  floor  and  raise  the  heels,  so  that  the  feet  are  at  as 
acute  an  angle  to  the  trunk  as  possible.  Finally,  the  patient 
should  rest,  physically  and  mentally,  and  as  far  as  possible 
out-of-doors.  Tabetics  do  best  in  summer,  and  in  a  dry  warm 
climate. 

Anti-luetic  therapy  should  be  pushed  to  physiological  tol- 
erance. Upon  this  depends  our  greatest  hope  of  arresting  the 
progress  of  the  disease,  and  in  this  way  preventing  further 
attacks.  The  various  forms  of  mercury  with  potassium  iodid 
are  effective  in  breaking  down  the  spirochetal  invasion,  and 
the  arsenical  preparations,  salvarsan  and  its  allies,  by  intra- 


ACUTE  ENTERITIS.  837 

muscular,  intravenous,  and  intraspinal  injection,  are  invalu- 
able in  this  endeavor.  These  remedies  should  be  given  in 
courses,  alternating  with  periods  of  mercury  and  the  iodids, 
and  with  salvarsan. 

All  cases  should  be  closely  followed  and  treated  until,  and 
for  some  time  after,  all  active  symptoms  and  findings  have 
been  eliminated.  Certainly  intensive  treatment  should  be  per- 
sisted in  until  the  spinal  fluid  cell-count  has  been  restored  to 
normal,  until  the  Wassermann  reaction  has  become  negative, 
and,  if  possible,  until  the  globulin  excess,  which  is  the  last  to 
clear  up,  has  been  reduced  to  normal. 

The  operative  treatment  has  already  been  discussed,  and 
need  not  be  recounted  here,  except  to  warn  once  more  against 
too  hasty  recourse  to  surgery,  until  the  attacks  are  unbeara1^1e, 
and  all  other  measures  have  proved  failures.      [B.  B.  V.  L.] 


DISEASES  OF  THE  INTESTINES. 
ACUTE    ENTERITIS. 

This  affection  is  all  too  often  confounded  with  diarrhea, 
since  the  cause  of  each  is  largely  the  same,  the  presence  of 
large  watery  dejections  being  the  cardinal  symptom  of  acute 
enteritis.  There  may  be  fifteen,  twenty,  or  more  stools  in  the 
course  of  twenty-four  hours,  the  abundant  liquid  resulting 
either  from  diminished  absorption  or  from  serous  exudation 
from  the  intestinal  wall.  The  evacuations  are  homogeneous, 
or  contain  particles  of  undigested  food.  The  color  of  the  stool 
is  dependent  upon  the  quantity  of  the  bile  or  blood  present. 
The  absence  of  bile  gives  rise  to  the  clay-colored,  feculent 
stool,  while  the  escape  of  large  quantities  of  bile  into  the  in- 
testinal canal  produces  a  grass-green  evacuation.  As  the 
movements  diminish  in  number,  the  color  becomes  yellow  or 
yellowish-brown.  Blood  is  rarely  present  in  the  acute  variety, 
and  the  same  applies  to  the  presence  of  mucus.  The  dis- 
charges may  be  of  a  serous  nature,  combined  with  a  small 
quantity  of  undigested  food,  or  have  a  semi-solid  consistency. 
Microscopically,  they  consist  of  large  masses  of  epithelium, 
many  varieties  of  fung"i,  mucous  leucocytes,  calcium  phos- 
phate, oxalates,  and  shreds  of  undigested  food   (starch-gran- 


838  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

ules,    fat,   vegetable,    and    muscular   libersj.      The    stools    are 
alkaline  in  reaction. 

The  passage  of  the  large  water}-  discharges  produces  a 
feeling  of  prostration,  and  the  patient  complains  of  pronounced 
languor  and  persistent  headache.  The  temperature  mounts 
to  103°  F.  (39.4°  C.)  or  higher.  There  may,  or  may  not  be 
loss  of  appetite,  nausea,  and  vomiting.  Abdominal  pain,  of  a 
spasmodic  character,  usually  associated  with  rumbling  bor- 
bor3-gmus,  is  characteristic  of  the  attack.  The  pain  is  usually 
referred  to  the  lower  abdomen,  but  it  may  be  located  in  the 
colon,  or  follow  the  course  of  the  sigmoid  flexure ;  the  presence 
of  the  inflammator}^  process  in  the  rectum  occasions  painful 
tenesmus. 

TREATMENT. 

If  the  attack  be  caused  by  some  indiscretion  in  diet,  a  mild 
purgative,  followed  by  regulation  of  diet,  is  usually  all  that  is 
required.  A  full  dose  of  castor  oil,  or  the  exhibition  of  calomel 
in  broken  doses,  is  generally  most  efficient.  Albuminous  food 
in  liquid  form,  such  as  skimmed  milk  or  broths,  and  the  em- 
ployment of  various  milk  modifications,  such  as  junket,  pep- 
tonized milk,  milk  and  seltzer,  lightly  boiled  or  poached  eggs, 
and  03'sters,  all  are  to  be  recommended,  AVhen  the  chief  seat 
of  the  disease  is  in  the  large  intestine,  easily  digested  starches 
and  certain  green  vegetables  are  allowable;  these  include 
sago,  lettuce,  watercress,  and  arrowroot.  The  tendenc}'  to 
drink  water  constantly  should  be  restrained,  as  tending  to  in- 
crease the  diarrhea,  and  in  its  place  may  be  substituted  oatmeal 
water,  cold,  weak,  unsweetened  tea,  barley  water,  brandy  and 
soda,  or  iced  champagne.  Rest  in  bed  is  especially  beneficial, 
in  that  it  tends  to  keep  the  abdomen  warm  and  to  mitigate 
the  pain.  The  use  of  the  hot  water  bottle,  the  employment  of 
spice  plasters,  mustard  poultices,  and  the  judicious  applica- 
tion of  any  of  the  various  rubefacients  often  distinctly  relieves 
the  pain.  A  flannel  bandage  should  be  worn  day  and  night. 
When  the  chief  tenderness  is  limited  to  the  right  iliac  fossa, 
a  simple  enema,  given  slowly,  will  exert  a  marked  sedative 
influence  upon  the  colon,  and  offers  a  far  more  rational  mode 
of  treatment  than  would  the  administration  of  a  cathartic. 
Chief  reliance  is  to  be  placed  on  intestinal  antiseptics  and  as- 
tringents.      Among-    the     former,     salol     stands     preeminent 


CHRONIC  ENTERITIS.  839 

Naphthol  and  strontium  salicylate  are  both  antiseptic  and  car- 
minative. Any  of  these  may  be  prescribed,  singly  or  together, 
and  in  combination  witli  carbolic  acid  and  one  of  the  bismuth 
salts.  In  certain  cases  the  use  of  opium  acts  most  happily, 
and  the  same  applies  to  argentic  nitrate  and  the  extract  of  hy- 
oscyamus.  In  those  instances  where  the  intestinal  juices  have 
been  diminished  or  modified  by  the  pathologic  process,  a  com- 
bination of  pancreatin  and  sodium  bicarbonate  offers  an  effec- 
tive treatment. 

In  the  employment  of  astringents,  in  an  effort  to  check 
the  diarrheal  discharges,  many  a  physician  defeats  the  very 
object- that  he  is  seeking  to  attain,  and  he  too  often  wonders 
why  failure  is  the  reward  of  his  endeavor.  All  the  vegetable 
astringents  are  irritants.  The  discharges  from  the  bowels  are 
provoked  by  an  inflammation,  and  the  effort  of  the  physician 
should  be  to  correct  the  condition  that  provokes  the  diarrhea, 
rather  than  to  cure  the  diarrhea  itself.  Lead  acetate  is  more 
sedative  and  less  irritant  than  the  vegetable  astringents.  In 
the  latter  stages  of  the  disease  the  condition  may  be  one  of 
intestinal  relaxation,  when  astringents  will  be  demanded ; 
these,  of  course,  include  such  medicaments  as  sulphuric  acid, 
chalk  mixture,  catechu,  and  kino.  For  the  distressing  flatu- 
lence, the  alkaline  carbonates,  or  spirits  of  ammonia,  and  a  car- 
minative may  be  used  as  a  corrective.  If  the  colicky  pain  be 
severe,  %  or  %  of  a  grain  (0.00810  or  0.01080  Gm.)  of  morphin 
liypodermically  may  be  given,  in  addition  to  the  measures 
above  outlined. 

CHRONIC    ENTERITIS. 

Chronic  enteritis  is  anatomically  divided  into  the  chronic 
catarrhal  form,  the  pseudomembranous  (in  which  the  copious 
mucoid  secretion  takes  on  the  form  of  membrane  or  casts), 
and  the  ulcerative  form.  In  chronic  enteritis,  diarrhea  and 
constipation  often  alternate.  Usually  there  are  about  six 
stools  during  the  course  of  the  twenty-four  hours ;  pain  may 
or  may  not  be  a  symptom,  but  the  patient  complains  of  a 
feeling  of  weight  and  discomfort  in  the  abdomen. 

The  evacuations  contain  much  mucus,  often  with  little 
fecal  matter,  or  the  feces  and  mucus  may  be  intimately  mixed. 
There  may  be  distention  of  the  abdomen,  with  tympany  and 


840  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

the  occurrence  of  borborygmus.  Terxderness  on  palpation 
may  or  may  not  be  a  symptom.  The  patient  may  appear  well 
nourished  or  be  emaciated.  The  victim  of  this  affection  is 
nervous,  irritable,  dissatisfied,  easily  fatigued,  and  morose. 

TREATMENT. 

The  hygienic  treatment  of  this  troublesome  affection  is  all- 
important.  The  body  must  at  all  times  be  uniformly  warm 
and  dry.  Silk  or  all- woollen  undergarments  must  be  con- 
stantly worn.  Even  the  ankles  must  be  protected  against 
changes  in  temperature,  and  with  the  approach  of  cooler 
weather  the  wearing  of  the  house  slipper  is  to  be  guarded 
against. 

The  dietetic  management  of  the  case  is  of  paramount  im- 
portance. In  severe  cases  it  is  often  advisable  to  put  the  pa- 
tient upon  a  milk,  diet  for  several  weeks.  As  a  rule,  fatty  or 
saccharine  substances  are  interdicted.  Slow  eating  and  thor- 
ough mastication  are  imperative  adjuncts  in  the  dietetic  regime. 
The  menu  should  include  scraped  beef,  lean  meats,  and  bread. 
If  this  diet  is  too  sparse,  there  may  be  added  pancreatinised 
food;  and  baked  potatoes  and  other  farinaceous  foods  may  be 
treated  with  diastase  or  malt  extract,  although  as  a  rule 
starchy  foods  are  strongly  contraindicated.  Generally,  no 
veg'etables  should  be  allowed ;  well-boiled  rice  in  some  cases 
acts  as  a  happy  substitute.  Coffee  is  to  be  forbidden;  tea  may 
be  used  in  moderate  amounts.  Ice-cold  drinks  are  injurious, 
and  among  the  foods  to  be  avoided  may  be  cited :  very  rich 
milk,  green  vegetables,  raw  acid  fruits,  nuts,  all  fat  dishes, 
lobsters,  crabs,  shrimps,  pork,  veal,  and  all  sweets.  The  best 
form  of  alcoholic  stimulant  is  claret,  sherry,  or  brandy,  diluted 
three  or  four  times  its  volume  with  plain  water,  Vichy,  or 
Appolinaris.  The  use  of  various  mineral  waters  is  urg-ed  by 
many  observers ;  and  residence  for  some  weeks  at  one  of  the 
alkaline  mineral  springs  finds  many  advocates. 

The  amount  of  exercise  required  must  be  regulated  by 
each  particular  case.  In  those  cases  where  there  is  pro- 
nounced exhaustion,  rest  in  bed  is  to  be  enjoined;  and  the 
application  of  Swedish  movements  is  most  essential.  In 
other  cases  carefully  graded  exercises  are  to  be  advised. 

The  medicinal  treatment  consists  of  daily  irrigation  of  the 


ENTERITIS  IN  INFANTS.  841 

bowel  with  some  antiseptic  solution,  such  as  salicylic  acid, 
5  grains  (0.32  Gm.)  to  the  ounce;  boric  acid,  10  or  20  grains 
to  the  ounce  (0.65  or  1.3  Gm.  to  30  mils)  ;  creolin,  5  grains 
to  the  ounce,  (0.32  Gm.  to  30  mils)  ;  and  for  its  alterative 
action,  the  nitrate  of  silver  is  often  the  agent  par  excellence,  in 
the  proportion  of  4  or  5  grains  (0.26  or  0.32  Gm.)  of  the  nitrate 
of  silver  to  each  pint  (473  mils)  of  water  to  be  injected.  The 
fluid  should  have  a  temperature  of  90°  or  95°  F.  (32.2°  or 
35°  C),  be  introduced  slowly,  and  at  least  one  quart  (1  1.)  of 
the  solution  introduced  at  each  sitting.  These  irrigations  are 
much  more  to  be  depended  upon  than  the  employment  of  as- 
tring-ent  remedies,  because  the  arrest  of  the  diarrhea  by  means 
of  astringents  is  only  temporary,  and  is  almost  always  suc- 
ceeded by  an  increase  in  severity  of  the  original  condition 
rather  than  by  its  betterment.  Among  the  more  valuable  in- 
ternal remedies  may  be  mentioned  the  nitrate  of  silver,  lead 
acetate,  bismuth,  especially  in  combination  with  carbolic  acid, 
or  turpentine.  It  should  always  be  borne  in  mind  that  all 
agents  intended  to  influence  the  intestinal  mucous  membrane 
should  be  exhibited  an  hour  or  two  following  a  meal,  cor- 
responding to  the  time  when  the  stomach  contents  are  passing 
into  the  small  intestine.  In  prescribing  certain  drugs,  such  as 
the  nitrate  of  silver,  the  fact  must  not  be  lost  sight  of  that 
destructive  changes  in  the  presence  of  the  gastric  juice  makes 
it  incumbent  upon  the  physician  to  instruct  the  pharmacist  to 
enclose  such  a  pill  in  a  double  capsule,  so  that  the  medica- 
ment may  exert  its  full  influence  upon  the  inflamed  surface  of 
the  bowel.  This  affection  is  difficult  of  treatment,  so  that 
remedial  measures  need  to  be  energetically  and  patiently  car- 
ried over  long  periods  of  time. 

ENTERITIS    IN    INFANTS. 

This  scourge  of  our  large  cities  during  the  hot  season  is 
variously  designated  summer  diarrhea,  enterocolitis,  diarrhea 
and  enteritis,  febrile  diarrhea,  and  inflammatory  diarrhea.  It 
is  always  associated  in  the  lay  mind  with  the  "second  sum- 
mer," although  isolated  cases  are  not  rare  during  the  winter 
season.  Hot,  damp,  weather  is  especially  conducive  to  the 
condition,  and  of  all  the  months  August  ofliers  the  greatest 


842  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

mortality,  because  during  this  month  the  high  daily  tempera- 
ture is  maintained  throughout  the  night. 

The  greatest  number  of  victims  is  found  between  the  ages 
of  six  months  and  eighteen  months.  The  invasion  of  the 
malady  depends  upon  the  sympathetic  irritation  of  the  alimen- 
tary canal,  in  association  with  the  eruption  of  the  teeth,  the 
increased  tendency  to  inflammation,  engendered  by  the  rapid 
development  that  the  intestinal  follicles  and  glands  are  simul- 
taneously undergoing,  and  the  fact  that  weaning  is  often  prac- 
tised during  this  critical  season.  In  brief,  the  hot  season,  con- 
taminated city  atmosphere,  bad  food,  improper  housing,  in- 
sufificient  nutrition,  unsuited  articles  of  diet,  and  excesses  of 
farinaceous  food,  all  are  potent  factors  in  the  production  of 
the  condition.  Breast-fed  babies  are  less  prone  to  enteric  affec- 
tions, but  they  also  may  fall  victims  from  too  frequent  or  con- 
tinuous feeding,  or  from  abnormalities  in  the  mother's  milk. 

Twenty-four  or  forty-eight  hours  before  the  attack  the 
child  is  restless  and  fretful,  his  sleep  is  broken,  he  looks  pale, 
and  the  mother  tells  the  doctor  that  the  child's  head  "feels 
feverish."  The  baby  will  not  take  the  bottle,  or  if  it  does, 
sour  eructations  are  almost  certain  to  follow,  and  at  the  same 
time  the  bowel  movements  are  frequent  and  soft  in  consist- 
ency. Obstinate  vomiting  now  sets  in,  and  this  is  followed 
by  a  large  number  of  loose  stools,  acid  in  reaction,  andj  pass- 
ing from  yellow  to  a  grass-green  in  color.  The  diaper  may 
appear  "slimy,"  or  much  mucus  stained  with  blood  is  passed. 
So  intense  are  the  symptoms  at  times  that  the  tenesmus 
occasioned  may  be  associated  with  slight  prolapse  of  the 
rectum. 

The  tongue  Is  dry  and  red  at  the  tip  and  edges,  there  is 
no  appetite,  and  thirst  is  increased.  For  the  first  few  days 
there  is  moderately  high  fever,  and  later  the  pyrexia  is  remit- 
tent; the  pulse  is  weak,  and  runs  as  high  as  from  120  to  140 
per  minute ;  the  urine  is  scanty,  hig-h-colored,  and  passed  at 
long  intervals. 

As  the  diarrhea  continues,  the  face  becomes  pale,  the  eyes 
sunken,  the  muscles  flabby,  and  there  is  intense  prostration. 
The  decreased  amount  of  the  urine  may  herald  the  fatal  ter- 
mination, with  uremic  poisoning  as  the  cause  of  death. 


ENTERITIS  IN  INFANTS.  843 

TREATMENT. 

The  prophylaxis  is  the  avoidance  of  the  dangers  of  sum- 
mer diarrhea  by  taking  the  child  to  the  country,  mountains, 
or  sea  shore,  where  the  air  is  cooler,  and  uncontaminated,  and 
where  pure  and  clean  milk  can  be  obtained. 

Among  the  poorer  classes  the  child  should  be  taken  to  the 
public  parks,  also  on  a  mornings  and  evening"  trip  on  a  river 
boat,  be  given  cool  baths,  and  be  cleanly  clad.  The  room  and 
the  bed  should  be  scrupulously  clean.  Good  ventilation  is  a 
prime  essential. 

The  child  should  not  be  fondled  or  carried;  it  should  be 
kept  in  bed  or  wheeled  around  in  a  coach.  Light  woolen 
clothing  should  be  next  the  child's  skin ;  otherwise  the  apparel 
should  be  of  the  lightest  texture.  Twice  or  thrice  daily  a  bath 
of  80°  F.  (26.7°  C.)  is  an  excellent  measure ;  with  marked 
prostration,  the  warm  bath  is  to  be  urged. 

Overfeeding  at  the  breast  is  to  be  guarded  against,  and  the 
same  applies  to  the  bottle-fed  baby.  The  high  fever  and  loss 
of  fluid  in  the  discharges  produces  a  marked  thirst,  and  it  is 
important  to  see  that  the  milk  secured  for  the  little  one  is 
absolutely  fresh,  and  from  a  responsible  dealer.  The  milk 
should  be  administered  from  an  absolutely  clean  bottle,  and  in 
the  intervals  the  rubber  nipple  always  should  be  turned  inside 
out,  cleansed  of  all  curds  and  detritus,  and  thrown  in  a  vessel 
of  water  in  which  a  small  quantity  of  borax  or  sodium  bicar- 
bonate has  been  previously  dissolved.  When  the  milk  or  one 
of  its  modifications  is  vomited,  or  passes  undigested  from  the 
bowels,  a  whey  mixture  may  be  employed,  beef  juice  may  be 
tried,  br  flour  ball ;  or,  if  none  of  these  seems  to  agree  with 
the  child,  all  food  should  be  withdrawn  for  from  twenty-four 
to  forty-eight  hours,  and  the  infant  placed  upon  barley  water. 
Cool  sterile  water  and  particles  of  ice  may  be  used  to  relieve 
the  intense  thirst. 

The  drug  treatment  consists  in  emptying  the  bowels  by 
means  of  castor  oil;  in  great  irritability  of  the  stomach,  an 
enema  should  take  its  place.  For  a  child  of  six  months,  a 
pint  (473  mils)  of  water  at  a  temperature  of  65°  or  70°  F. 
(18.3°  or  21.1°  C.)  is  to  be  employed,  and  the  injection  slowly 
given.    Calomel  and  the  salicylate  of  sodium  are  both  antisep- 


844  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

tic,  and  are  capable  of  great  good.  The  calomel  can  be  given 
in  the  usual  small  broken  doses;  the  salicylate  in  doses  of  a 
grain  or  two  (0.065  to  0.130  Gm.),  dissolved  in  peppermint  or 
cinnamon  water.  Counterirritation  to  the  abdomen,  or  ap- 
plication of  different  forms  of  heat,  or  the  spice  plaster,  are 
all  beneficial  and  comforting.  When  prostration  sets  in, 
stimulants  are  demanded,  depending  in  quantity  and  frequency 
upon  the  age  and  the  condition  of  the  child. 

CHOLERA    INFANTUM. 

The  severest  and  gravest  form  of  acute  enteritis  in  infants 
is  known  as  cholera  infantum.  Here  the  vomiting  becomes 
excessive,  and  the  watery  stools  may  number  thirty  or  more 
in  the  twenty-four  hours.  Painful  cramps  in  the  muscles  of 
the  extremities  may  take  place,  and  a  condition  of  collapse 
rapidly  supervenes.  The  superficial  temperature  is  often  sub- 
normal, but  the  rectal  temperature  shows  the  presence  of 
fever,  and  there  may  be  hyperpyrexia,  anteceding  death. 

The  stomach  becomes  irritable,  refusing  everything;  even 
ice  is  rejected.  The  child  drinks  with  avidity  at  ever}^  possible 
chance,  piteously  looking  at  the  receding  empty  glass — a 
mute  appeal  for  a  cooling  substance  to  quench  the  consuming 
thirst. 

A  little  later  the  baby  lies  still  and  apathetic;  the  face  is 
drawn,  the  skin  is  clammy,  the  pulse  is  small  and  rapid ;  and 
when  death  supervenes  not  uncommonly  it  is  preceded  by  a 
conA'ulsion ;  or  the  child  first  passes  into  a  prolonged  coma 
that  gradually  fades  into  an  endless  sleep.  The  prognosis 
always  is  grave.  Death  often  occurs  within  forty-eight  hours 
after  the  invasion  of  the  disease.  In  cases  of  recover}^,  con- 
valescence is  much  protracted. 

TREATMENT. 

AVhat  has  been  said  of  the  treatment  of  acute  enteritis  in 
infants  applies  with  equal  force  in  treating  cases  of  cholera 
infantum  (vs.).  The  large  watery  evacuations  are  so  ex- 
hausting to  the  child  that  it  becomes  at  once  imperative  to 
check  these  discharges,  and  to  maintain  the  bodily  strength  by 
food  and  drink.     In  spite  of  the  irritability  of  the  stomach, 


CHRONIC  MUCOUS  COLITIS.  845 

every  effort  must  be  made  to  give  food  in  small  quantities, 
and  at  short  intervals.  To  check  the  diarrhea,  opium  and  as- 
tringents need  be  exhibited.  Stimulants  are  demanded  very 
early  in  the  affection  to  prevent  the  occurrence  of  prostration. 
Whisky  or  cognac,  5  or  10  drops  (0.30  or  0.60  mils)  in  a 
dram  (3.75  mils)  of  limewater,  may  be  given  every  thirty 
minutes  to  a  child  six  months  old.  When  collapse  occurs, 
the  amount  of  stimulant  must  necessarily  be  increased,  and 
given  at  more  frequent  intervals.  In  conjunction  with  alco- 
holic stimulants,  a  diffusible  cardiac  stimulant  as  the  carbo- 
nate of  ammonia  is  especially  useful. 

The  temperature  must  be  maintained  by  hot  water  bottles, 
and  the  child  kept  in  a  lying  posture,  and  disturbed  as  little 
as  possible.  The  presence  of  cerebral  symptoms  is  a  contra- 
indication to  the  use  of  opium.  For  other  details  of  treatment, 
including  the  hygienic  management,  etc.,  the  reader  is  referred 
to  Acute  Enteritis  in  Infants.     (See  p.  841.) 

ACUTE  COLITIS. 

This  is  one  of  the  special  forms  of  enteric  catarrh,  each 
variety  manifesting  certain  symptoms,  according  to  the  par- 
ticular part  of  the  bowel  affected,  and  these  are  variously 
designated:  duodenitis,  localized  catarrh  of  the  jejunum  and 
the  ileum,  and  proctitis.  The  joint  appearance  of  abdominal 
pain  and  loose  dejections  is  almost  diagnostic  of  acute  colitis. 
There  is  tenderness  on  palpation  over  the  region  of  the  colon ; 
the  stools  contain  blood,  and  often  large  quantities  of  mucus. 
the  latter  not  being  mixed  with  the  fecal  mass,  as  in 
catarrhal  conditions  of  the  small  intestine.  The  patient  ap- 
pears pale  and  emaciated ;  weakness  and  sallowness  of  the 
skin  are  often  observed. 

The  treatment  is  that  of  acute  enteritis  (v.s.). 

CHRONIC    MUCOUS    COLITIS. 

The  distinction  made  between  mucous  and  membranous 
colitis  is  one  that  cannot  well  be  maintained.  The  peculiar 
symptom-complex  variously  described  as  membranous  colitis, 
membranous  enteritis,  pseudomembranous  enteritis,  and 
fibrous   enteritis,   is   primarily   a   disease   of  the   female   sex. 


846  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

From  80  to  90  per  cent,  of  the  cases  are  found  in  women. 
These  women  all  exhibit  well-marked  neurotic  or  hysterical 
symptoms;  and  even  the  small  proportion  of  males  aftected 
evidence  the  same  nervous  phenomena.  In  1871,  Dr.  J.  ^1- 
Da  Costa,  df  Philadelphia,  wrote  a  most  elaborate  treatise  on 
the  subject,  and,  although  almost  half  a  centun,-  has  since 
elapsed,  nothing  of  an  important  character  has  been  added  to 
the  knowledge  contained  in  that  masterful  essay. 

Originally  Da  Costa  maintained  that  mucous  colitis  was  no 
colitis  at  all,  but  a  secretory  neurosis,  attended  with  an  exces- 
sive secretion  of  mucus  in  the  colon,  and  it  has  been  frequently 
suggested  since  that  time  that  all  the  synonyms  mentioned 
at  the  opening  of  this  article  be  dropped,  and  in  their  place 
the  term  membranous  or  mucous  colic  be  substituted. 

The  aiTection  is  characterized  by  the  passage  t)f  a  greyish- 
white  translucent  substance,  preceded  by  a  colicky  pain. 
Sometimes  these  masses  appear  as  shreds,  or  lumps,  or  balls, 
or  as  membrane  conforming  to  the  shape  and  caliber  of  the 
intestinal  canal.  The  amount  of  this  substance  may  be  large 
or  small,  and  the  feces,  as  a  rule,  are  rarely  passed  with  this 
material.  When  allowed  to  float  upon  the  surface  of  water 
these  masses  are  rolled  up,  and  produce  a  lumpy  appearance, 
while  chemically  the  substance  is  found  to  be  mucin,  although 
at  first  it  was  incorrectly  designated  fibrin;  hence  the  erron- 
eous term,  fibrous  enteritis.  It  is  worthy  of  note  that  leuco- 
cytes are  found  in  extremely  small  numbers  in  this  newly 
formed  substance ;  hence  there  is  no  suggestion  in  the  studv 
of  the  subject  to  suspect  inflammation  or  suppuration. 

With  the  discharge  of  these  mucoid  masses  the  colic  is  at 
once  relieved.  There  may  be  intervals  of  weeks,  or  even 
months,  between  these  attacks,  the  patient  appearing  perfectly 
well  in  the  interA'al.  The  length  of  the  attack  may  be  hours, 
days,  weeks,  or  months.  The  pain  is  described  as  cutting, 
burning,  shooting,  or  stabbing.  The  pain  may  be  felt  at  the 
sigmoid  flexure  or  cecum,  and  radiates  most  often  toward  the 
umbilicus  and  epigastrium,  or  at  times  down  the  thighs,  espe- 
cially on  the  left  side.  Xausea  is  often  a  SA-mptom ;  but  there 
is  no  vomiting  and  no  fever.  Enteroptosis  and  gastric  hvper- 
acidity  are  often  concomitant  symptoms.  Pathologicallv,  no 
anatomic  lesion  has  up  to  the  present  time  been  found. 


CHRONIC  MUCOUS  COLITIS.  847 


TREATMENT. 


The  therapeusis  of  this  peculiar  malady  is  difficult  of  de- 
scription, because  of  the  neurotic  or  hysterical  element  too 
often  forming  the  groundwork  of  the  symptom-complex. 
The  patient's  confidence  must  be  won  at  the  outset.  The  diet 
should  be  as  liberal  as  possible,  in  order  to  sustain  the  bodily 
vigor  and  to  counteract  constipation.  Exercise  in  the  open 
air  and  hydrotherapeutics  are  to  be  encouraged.  Lavage  of 
the  bowels,  by  means  of  high  injections,  thus  causing  colonic 
flushings,  are  to  be  highly  recommended.  Astringent  injec- 
tions, especially  of  the  nitrate  of  silver,  are  of  decided  benefit. 
These  enemata  should  be  employed  at  least  thrice  weekly,  and 
may  be  varied  by  the  addition  of  borax  or  common  salt  in  the 
proportion  of  2  or  4  per  cent,  up  to  saturation.  Two  quarts 
(2  1.)  of  solution  should  be  used  at  each  sitting,  the  water  hav- 
ing a  temperature  of  105°  F.  (40.5°  C).  It  should  be  re- 
marked, however,  that  not  a  few  clinicians  mention  lavage 
and  injections  in  these  classes  of  cases  merely  to  condemn 
these  procedures  as  productive  of  an  increased  secretion  of 
mucus  in  the  colon. 

The  abdominal  bandage  should  be  worn  day  and  night, 
and  daily  bathing  is  an  invaluable  hygienic  measure  not  to  be 
overlooked.  In  the  dietary,  oatmeal  is  forbidden ;  potatoes, 
beets,  and  other  vegetables  that  grow  under  the  ground  are 
prohibited;  spinach,  young  peas,  or  lima  beans  can  be  spar- 
ingly eaten.  Rice,  cheese,  and  milk  foods  are  permitted. 
Toast  bread  and  pulled  bread  are  far  more  preferable  than 
fresh  bread.  Tea  is  to  be  chosen  rather  than  cofifee  or  choc- 
olate. Alcohol  may  be  used  sparingly,  but  malt  liquors  are 
especially  injurious.  During  the  paroxysms  the  patient  should 
be  kept  quiet  in  bed ;  counterirritation  along  the  course  of  the 
colon  may  be  practised  in  suitable  cases,  and  the  administra- 
tion of  castor  oil  until  its  effects  are  manifest  should  be  a 
routine  practice,  at  the  same  time  using  the  injections  as  just 
described.  Diarrhea  is  to  be  controlled  by  some  mild  astrin- 
gent, of  which  dilute  sulphuric  acid  is  the  drug  pOA'  excellence. 
In  the  event  of  constipation,  no  hesitation  should  be  felt  in 
the  use  of  laxatives,  which  should  be  varied  from  time  to  time. 
Among  the  more  efficient  ones  may  be  cited :    cascara,  an  oc- 


848  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

casional  dose  of  calomel,  a  combination  of  the  vegetable 
cathartics,  sodium  phosphate,  and  the  A.S.B.  pill.  The  salines 
in  uncomplicated  cases,  in  which  there  is  no  catarrh  of  the 
bowels,  are  not  to  be  recommended.  Opium  is  to  be  used  only 
to  relieve  pain  and  tenesmus,  and  other  measures  should  be 
first  employed  before  resorting  to  this  drug,  which  really  has 
no  place  in  the  treatment  of  mucous  colitis. 

ULCERATIVE    COLITIS. 

Ulcerative  colitis  is  often  associated  with  chronic  intest- 
inal catarrh,  and  is  a  not  uncommon  complaint.  As  a  rule, 
the  ulcers  are  quite  extensive,  and  tend  to  denude  the  greater 
portion  of  the  mucous  membrane.  Two  varieties  are  recog- 
nized :  the  catarrhal,  extending  from  the  surface  downward ; 
the  other,  the  follicular,  proceeding  from  an  abscess  of  the 
lymph  follicle  in  the  wall  of  the  bowel. 

Ulcers  of  the  intestine  give  rise  to  few  characteristic  symp- 
toms. Indeed,  diarrhea  may  be  the  only  symptom  present; 
and  when  the  ulcers  are  large  and  numerous,  the  course  of 
the  affection  is  that  of  acute  or  chronic  enteritis.  Pain  is  not 
a  dependable  S3^mptom,  but  when  present  it  is  of  a  colicky, 
griping  nature.  When  sharph-  localized,  and  markedly  sensi- 
tive in  that  particular  region,  extension  of  the  morbid  process 
to  the  peritoneum  is  strongly  suggested.  The  presence  of  pus, 
blood,  or  shreds  in  the  dejections  would  be  stronglv  confirm- 
atory of  the  existence  of  ulcer,  but  any  of  these  is  rarely  to 
be  found.  When  the  amount  of  pus  discharged  is  at  all  ap- 
preciable, the  presence  of  abscess  and  not  ulcer  is  to  be 
surmised. 

The  general  health  suft'ers  little  from  the  existence  of  these 
ulcers.  But  perforation  of  the  ulcers,  depending  upon  their 
location,  may  lead  to  a  general  peritonitis.  Stricture  of  the 
bowel  or  embolism  of  the  portal  vein  may  follow  ulceration. 

TREATMENT. 

The  treatment  of  ulcers  in  the  upper  bowel  is  practically 
the  treatment  of  chronic  enteritis.  In  ulceration  of  the  large 
intestine  the  treatment  is  virtually  that  of  chronic  enteritis, 
plus  local  medication.     Intestinal  antiseptics,  such  as  salol, 


APPENDICITIS.  849 

are  especially  valuable,  as  they  remedy  complicating  condi- 
tions in  the  small  intestine.  Bismuth  is  perhaps  the  only  drug- 
taken  by  the  mouth  which  reaches  the  large  intestine ;  it  must 
always  be  prescribed  in  large  dosage. 

Greatest  dependence,  however,  is  to  be  placed  upon  in- 
testinal irrigation.  Twice  or  thrice  weekly,  an  injection  of 
2  quarts  (2  1.)  of  water,  containing'  30,  40,  or  50  grains  (1.95, 
2.60,  or  3.25  Gms.)  of  nitrate  of  silver,  is  often  productive  of 
most  excellent  results ;  and  in  the  intervals,  once  or  twice 
weekly,  the  bowels  are  to  be  irrigated  with  a  saturated 
solution  of  borax. 

In  the  treatment  of  ulcerative  colitis  during  the  acute 
stage,  much  of  the  success  to  be  obtained  consists  in  the  care- 
ful reg'ulation  of  the  diet,  confining  the  patient's  dietary 
to  liquids  and  semisolids,  and  maintaining  the  bowels  in  a 
soluble  condition. 

APPENDICITIS. 

The  term,  appendicitis  was  first  proposed  by  the  late  Pro- 
fessor Reginald  H.  Fitz,  of  Harvard  University,  to  designate 
that  important  primary  disease  of  the  right  iliac  fossa  that, 
among  other  appellations,  had  been  variously  called  iliac  ab- 
scess, iliac  phlegmon,  perityphlitis,  and  paratyphlitis.  In  his 
elaborate  studies,  he  emphasized  the  fact  that  the  above- 
named  affections  had  so  many  points  in  common  with  perfor- 
ation of  the  vermiform  appendix :  "that,  for  all  practical  pur- 
poses, typhlitis,  perityphlitis,  typhlitic  tumor,  and  perity- 
phlitic  abscess  meant  inflammation  of  the  vermiform  appen- 
dix ;  that  the  chief  danger  of  this  afl^ection  is  perforation ; 
that  perforation  in  the  great  majority  of  cases  produces  a 
circumscribed  suppurative  peritonitis,  tending  to  become 
generalized." 

The  great  frequency  of  appendicitis,  finds  a  ready  etiology 
both  in  congenital  and  acquired  conditions.  Thus,  in  the  new- 
born babe,  the  appendix  may  be  unusually  long,  or  it  may 
occupy  an  abnormal  position,  or  there  may  be  something 
anomalous  in  the  development  of  its  mesentery,  which  abnor- 
malities all  tend  to  favor  the  accumulation  of  matter  within 
the  canal.  In  the  acquired  variety,  the  existence  of  adhesions 
dependent  upon  inflammation  of  the  appendix  or  other  part  of 


850  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

the  general  abdominal  cavity,  may  bind  down  the  appendix 
and  prevent  it  from  expelling  its  contents.  Digestive  disturb- 
ances may  be  a  cause,  and  the  occurrence  of  influenza  as  favor- 
ing the  development  of  the  affection  finds  not  a  few  advocates. 
Fecal  concretions,  foreign  bodies,  strains,  jars,  and  traumatism 
all  are  factors  of  etiologic  importance.  Often,  however,  the 
disease  occurs  without  apparent  cause.  It  is  commoner 
among  males  than  females,  and  statistics  record  its  presence 
in  a  child  of  eighteen  months;  and  then  again  in  a  man  of 
eighty.  It  is  most  frequently  met  with  between  the  ages  of 
ten  and  thirty;  and  out  of  three  hundred  post  mortems,  the 
appendix  has  been  found  to  be  diseased  in  one  hundred  and 
ten  instances. 

The  appendix  may  be  affected  and  the  attack  so  latent,  as 
either  to  produce  no  symptoms,  or  the  inconvenience  be  so 
slight  as  to  be  inconsequential  to  the  patient.  Ordinarily, 
however,  appendicitis  may  be  classified  as  acute  and  chronic. 

The  acute  variety  is  characterized  by  abdominal  pain, 
slight  or  severe,  in  association  with  a  chill  or  some  chilliness. 
Possibly  for  a  day  or  two  the  patient  has  felt  somewhat  in- 
disposed with  slight  undefinable  symptoms,  or,  as  often  is  the 
case,  the  sufferer  was  enjoying,  apparently,  the  best  of  health. 

The  pains  are  at  first  diffused  over  the  abdomen,  probably 
because  the  superior  mesenteric  plexus  of  the  sympathetic 
supplies  both  the  appendix  and  a  large  portion  of  the  intes- 
tines ;  a  little  later  the  discomfort  manifests  itself  at  the 
umbilicus,  where  the  intensity  of  pain,  following  the  physio- 
logic law,  is  felt  at  the  nearest  great  nerve  center,  which  in 
these  cases  are  the  great  abdominal  sympathetic  ganglia  situ- 
ated in  the  umbilical  region.  The  pain,  at  first  colicky,  is 
localized  a  few  hours  later  in  the  right  iliac  fossa,  when  a 
neuritis  has  developed  of  sufficient  grade  to  cause  tenderness 
on  pressure. 

This  point  of  pain  upon  pressure,  commonly  designated 
"McBumey's  point,"  is  near  the  outer  edge  of  the  right  rectus 
muscle,  on  a  line  between  the  navel  and  the  anterior  superior 
spine  of  the  ilium.  Depending  upon  the  topographic  position 
of  the  appendix,  the  point  of  greatest  tenderness  may  be  found 
elsewhere  in  the  right  iliac  fossa  or  even  in  the  left  iliac  fossa, 
the  groin,  and  either  the  umbilical  or  the  lumbar  region. 


APPENDICfTIS.  851 

Vomiting  commonly  follows,  with  little  relation  to  the 
gastric  conditions,  and  is  ordinarily  reflex  and  due  to  reversed 
peristalsis.  The  material  ejected  is  that  which  the  stomach 
contains ;  a  little  later  it  consists  of  mucus,  sometimes  bile- 
stained  ;  but  the  stercoraceous  vomiting  of  hernia  is  not 
encountered. 

Moderate  fever,  99.5°  to  101°  F.  (37.2°  to  38.3°  C.)  with  a 
corresponding  increase  of  pulse-rate  are  usually  present. 

There  is  slight  rigidity  of  the  right  rectus  abdominalis 
muscle,  and  later  of  the  musculature  over  the  right  iliac  fossa. 
Respiration  is  but  little  affected.  There  is  anorexia,  and  the 
vomiting  before  mentioned  is  a  symptom  of  the  onset  of  the 
malady,  but  later  disappears  unless  general  peritonitis  is  pres- 
ent. Constipation  is  the  rule,  although  diarrhea  sometimes 
precedes  the  attack,  and  may  be  a  late  symptom  in  protracted 
cases. 

So  long  as  the  disease  is  limited  to  the  appendix,  the  swell- 
ing is  not  well  made  out ;  in  those  cases  where  the  appendix 
lies  posterior  to  the  cecum,  the  swelling  is  impossible  of 
demonstration. 

TREATMENT. 

Although  a  discussion  of  surgical  measures  v\rould  be  ir- 
relevant in  a  work  such  as  this,  we  need  recognize  three  con- 
ditions when  surgical  interference  and  not  medical  treatment 
becomes  a  sine  qua  non. 

1.  In  all  cases  zuhere  the  initial  symptoms,  the  pain,  tender- 
ness and  tympany  are  excessive,  with  marked  acceleration  of  the 
pulse  and  temperature,  indicating  in  all  probability  the  occurrence 
of  an  acute  perforating  appendicitis. 

2.  In  cases  of  apparently  mild  appendicitis,  where  after  sev- 
enty-two hours  of  treatment,  there  is  no  amelioration  of  the 
symptoms.  Except  in  those  cases  where  fecal  masses  have  been 
discovered,  at  the  onset  of  the  attack,  at  the  position  of  the  head 
of  the  colon,  especially  if  there  has  been  tenderness  along  the 
course  of  the  colon  and  not  in  the  immediate  vicinity  of  the 
appendix. 

3.  An  immediate  operation  is  called  for  in  cases  showing  the 
symptoms  of  perforation — that  is,  collapse;  also  in  cases  zvhere 
the  symptoms  point  to  development  of  suppuration — the  exquisite 


852  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

tenderness,  elevation  of  temperature  and  acceleration  of  the 
pulse-rate,  being  the  ominous  symptoms  indicating  the  oncoming 
of  a  general  peritonitis. 

\M'ien  an  appendicitis  attack  has  progressed  several  days 
before  the  doctor  has  been  called  in — and  in  fact,  often  at  the 
outset  of  a  case — it  is  the  practice  of  many  careful  physicians 
to  ask  for  the  opinion  of  a  skilled  surgeon.  Let  it  be  remem- 
bered, that  about  the  third  or  fourth  day  of  the  affection,  ab- 
scess formation  is  likely  to  occur,  when  the  inflammation 
tends  to  circumscribe  itself  by  throwing  out  lymph  and  form- 
ing adhesions,  not  ver\-  strong — a  critical  time,  in  which  ''it 
is  too  late  for  an  early  operation  and  too  early  for  a  safe  late" 
operation." 

These  are  the  delicate  questions  that  require  nicety  of 
judgment  on  the  part  of  the  attending  physician.  Having  de- 
termined that  the  case  is  one  for  medical  treatment,  the  patient 
should  be  kept  in  bed  in  a  well-ventilated  room,  and  absolute 
quiet  be  enjoined.  The  diet  should  be  liquid  and  sustaining. 
It  should  consist  of  foods  that  will  be  thoroughly  absorbed, 
leaving  as  little  residue  as  possible  to  irritate  the  large  intes- 
tine and  provoke  peristalsis.  The  diet  should  be  made  up  of 
nutritive  broths,  beaten  eggs,  pancreatized  milk,  Avhey,  milk 
well  diluted  with  seltzer  acid  water,  or  lime  water,  and  butter- 
milk. 

At  the  onset  of  the  disease,  especially  if  a  "sausage-like" 
tumor  be  palpable,  intestinal  irrigation,  with  a  view  to  remov- 
ing the  fecal  accumulation,  is  to  be  assiduously  practiced.  The 
use  of  saline  laxatives,  until  the  bowels  have  been  thoroughly 
emptied  should  be  a  routine  practice.  It  is  the  custom  of 
very  many  careful  clinicians  to  administer  calomel  during  the 
course  of  the  disease,  providing  that  there  are  no  symptoms 
of  gangrene,  perforation  or  serious  septic  infection.  If  the 
physician  suspects  ulceration  or  gangrene  of  the  appendix 
then  purgatives  should  only  be  resorted  to  to  cleanse  the  bowels, 
if  fecal  accumulations  can  be  demonstrated.  It  is  a  matter  of 
clinical  experience  that  the  presence  of  fecal  matter  in  the 
colon  greatly  increases  the  danger  from  operation  upon  the 
appendix,  a  fact  that  must  never  be  lost  sight  of.  As  has  been 
just  rem.arked,  in  all  cases  of  appendicitis  high  injections  are 
always  a  valuable  measure;  and  these  are  absolutel}^  to  be  de- 


APPENDICITIS.  853 

pended  upon  in  ulceration  or  perforation  of  the  bowel,  the 
use  of  any  laxative  or  purgative  agent  by  the  mouth,  in  the 
presence  of  these  complications,  being  absolutely  contraindi- 
cated. 

Local  applications  consist  of  the  use  of  heat,  cgld,  leeches, 
and  blisters.  The  suspended  ice-bag  is  an  excellent  means  of 
relieving  pain ;  but  in  its  place  cloths  wet  in  ice-water  may 
be  applied  and  changed  every  few  minutes.  If  warmth  is  more 
agreeable  to  the  patient,  the  hot  water  bag  may  quite  happily 
l)e  substituted  for  the  ice-cold  application.  Leeches  are  very 
effective,  and  there  is  no  good  ground  for  any  antagonism  con- 
cerning their  employment.  The  same  does  not  hold  good  of 
blisters.  The  latter  are  extremely  discomforting  and  painful 
to  the  sufferer;  their  eft'ect  upon  the  spread  of  the  inflammation 
is  to  be  regarded  as  negligible,  and  the  raw  surface  that  they 
occasion  is  a  handicap  to  any  surgical  interference. 

There  exists  today  some  dift'erences  of  opinion  concerning 
the  use  of  opium.  The  consensus  of  opinion,  however,  does  not 
favor  the  use  of  the  drug,  for  it  checks  secretion,  interferes 
with  peristalsis,  masks  the  abdominal  pain,  and  leaves  the 
surgeon  hopelessly  wandering  in  the,'  darkness,  as  to  whether 
interference  should  be  adopted  or  not.  Unless,  therefore, 
opium  is  called  for  by  the  presence  of  excessive  and  unbear- 
able pain  it  is  best  to  avoid  it,  and  when  demanded  it  should 
be  given  in  the  form  of  hypodermic  injections  of  morphin,  in 
doses  of  from  ^  to  J4  of  a  grain  (0.00540  to  0.01620  Gm.). 
When  operation  has  been  decided  on,  morphin  may  be  given, 
however,  without  hesitancy.  Mild  counterirritation,  such  as 
the  use  of  mustard  paste  or  plaster,  is  practised  by  some  phy- 
sicians, in  the  hope  of  offering  some  relief  from  the  constant 
gnawing  pain,  but  even  these  applications  are  prone  to  pro- 
duce induration  of  the  integument  and  the  underlying  tissues. 
Sleeplessness  from  pain  is  to  be  met  with  morphin;  but  in- 
somnia which  may  proceed  in  the  wake  of  the  disease  is  to  be 
treated  with  one  of  the  synthetics,  such  as  trional  or  veronal. 
Chloral  in  these  cases  is  a  valuable  hypnotic. 

As  the  patient  convalesces,  he  should  not  be  permitted  to 
leave  his  bed  for  several  days  after  the  disappearance  of  all 
symptoms.  During  this  period,  the  diet  must  be  carefully 
rearulated  and  the  bowels  maintained  free  and  soft. 


854  DISEASES   OF   THE   DIGESTIVE   SYSTEM.      . 

CONSTIPATION. 

The  definition  of  habitual  constipation  might  well  answer 
for  synonyms  of  the  complaint  itself:  Chronic  fecal  retention ; 
habitual  infrequency  of  bowel  movements;  irregulafity,  in- 
sufficiency or  difficulty  of  the  evacuation  of  the  bowels.  The 
onward  passage  of  the  fecal  current  is  dependent  upon  peris- 
talsis. It  requires  four  hours  for  the  bowel  contents  to  pass 
through  the  small  intestine,  and  from  twelve  to  twenty  hours 
to  pass  from  the  cecum  to  the  anus.  In  the  vast  majorit}'  of 
cases  constipation  is  due  to  lack  of  peristaltic  and  expulsive 
power,  and  also  a  deficiency  of  hepatic  and  intestinal  secre- 
tions. The  causes  of  constipation  may  be  conveniently 
grouped  into  three  great  classes : 

(A)  (1)  G^»^ra/ causes  :  These  include  persons  of  a  nerv- 
ous temperment,  common  among  women,  especially  of  a 
brunette  type,  and  familiarly  known  among  the  laity  as  "torpor 
of  the  liver"  or  "sluggish  bowels."  A  sedentar}^  life,  develops 
the  "constipated  habit,"  and  this  also  applies  to  those  who, 
from  an  innate  sense  of  modesty,  either  do  not  permit  the 
bowels  to  move  in  the  retiring  rooms  of  public  places  or  who 
hurry  the  act,  because  of  the  ill-kept,  unsanitar}^  and  often 
semi-public  character  of  these  closets,  all  of  which  tend  to 
lessen  the  sensibility  of  the  rectum  to  the  exciting  action  of 
the  contained  fecal  accumulations. 

(2)  General  bodily  weakness  and  disease.  In  this  category 
is  included :  Nervous  affections — neurasthenia,  hysteria,  dis- 
eases of  the  brain  and  the  cord,  acute  fevers,  disorders  of  the 
liver,  habitual  use  of  purgatives,  acquired  degeneration  of  the 
muscular  coat  of  the  boAvels,  as  in  chronic  enteritis  and  chronic 
peritonitis. 

Abundant  diuresis  and  diaphoresis,  which  abstracts  large 
quantities  of  fluid  from  the  system,  may  engender  constipation. 

(B)  Local  causes :  These  include  atony  of  the  abdominal 
muscles,  as  occurs  from  obesity,  and  repeated  pregnancies ; 
atony  of  the  bowel  caused  by  pressure  from  tumors  ;  narrowing 
of  the  lumen  of  the  bowel  b}'-  growths  within  the  intestine  or 
by  pressure  from  without,  and  from  functional  intestinal 
neuroses. 

(C)  Dietary  causes:     These  include  insufficient  food,  be- 


CONSTIPATION.  855 

cause  the  small  bulk  of  aliment  fails  to  excite  peristalsis,  and 
there  is  an  accumulation  of  waste  products  as  a  consequence ; 
food  that  is  too  rich  or  too  highly  concentrated  is  often  com- 
pletely absorbed,  leaving  insufficient  residue  of  waste  matter 
to  provoke  peristalsis ;  astringent  food  and  drink,  by  checking 
mucous  and  other  secretions,  necessarily  increase  friction 
within  the  intestinal  tube ;  indigestible  food  may  be  im- 
,  perfectly  acted  upon  by  peristalsis  and  incompletely  mingled 
with  the  digestive  juices,  or  fermentation  may  develop  and 
the  production  of  substances  be  formed  which  interfere  with 
absorption  and  peristalsis;  irregularities  in  diet,  or  in  the 
intervals  of  taking  food,  irregular  mastication,  etc.,  not  in- 
frequently find  a  counterpart  in  the  irregularity  of  defecation 
or  in  its  partial  suppression ;  insufficient  fluid  is  a  frequent 
cause  of  constipation. 

TREATMENT. 

This  comprises  the  hygienic,  dietary,  remedial,  and  me- 
chanical measures.  The  hygienic  regime  includes  the  habit  of 
defecation  at  a  particular  time  each  day  (there  should  be  at 
least  one  bowel  movement  in  the  course  of  the  twenty-four 
hours).  As  sedentary  habits  are  not  infrequently  the  causative 
factor,  systematic  graded  exercise,  whether;  in  the  open,  gym- 
nasium, or  at  home,  must  be  insisted  upon.  Walking  to  or  from 
the  place  of  business  is  applicable  to  every  busy  worker.  A 
glass  or  two  of  cool  water  upon  retiring,  and  again  immedi- 
ately upon  arising,  often  exerts  a  markedly  beneficial  effect. 
At  each  call  of  nature,  the  bowels  should  be  evacuated  as  com- 
pletely as  possible,  and  under  no  circumstance  should  the 
patient  defer  the  act. 

The  dietetic  measures  are  of  incalculable  importance.  The 
principle  of  treatment  is  based  upon  supplying  food  which  will 
provoke  peristalsis,  either  by  bulk  or  from  its  physical  and 
chemical  properties.  The  cellulose  of  certain  starchy  vege- 
tables is  difficult  to  digest,  and  is  of  little  nutritive  value,  yield- 
ing a  bulk  of  waste ;  among  these  are  potatoes,  corn,  peas, 
and  beans.  Other  vegetables  leave  a  large  residue  to  excite 
peristalsis.  These  include  tomatoes,  asparagus,  spinach,  cab- 
bage, and  celery. 

The  various  cereals  when  coarsely  ground  contain  a  large 


856  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

proportion  of  the  external  envelope  of  the  grains,  which  me- 
chanically irritates  the  intestines.  Thus,  the  following  articles 
tend  to  overcome  constipation :  r}'e,  corn  meal,  Indian  meal, 
oatmeal,  Boston  brown  bread,  whole-meal  bread  and  wheaten 
grits.  Again,  the  finest  white  flour  favors  constipation, 
because  it  contains  so  little  of  the  innutritious  part  of  the 
grain. 

Alolasses  and  honey  smeared  on  bread  are  laxative.  Brown 
sugar  has  a  marked  laxative  action ;  white  sugar  possesses  that 
power  to  a  very  slight  degree ;  sugar  of  milk  is  absolutely 
inert.  Among  the  fluids  exerting,  a  laxative  action  are :  cof- 
fee, beer,  cider,  unfermented  grape  juice,  olive  oil,  and  cod- 
liver  oil.  The  last  two  are  especially  useful,  when  there  are 
evidences  of  failing  nutrition  associated  with  constipation. 

Fruits  possess  a  laxative  action  either  because  they  contain 
indigestible  seeds  that  mechanically  irritate  the  intestines,  or 
from  some  inherent  property  are  capable  of  bringing  about  a 
chemical  action.  Many  fruits  act  in  both  ways.  Fruits  con- 
taining seeds  are :  strawberries,  blackberries,  huckleberries, 
figs,  and  grapes.  (Grapes  are  laxative  when  eaten  in  quantity 
and  the  seeds  rejected.) 

Fruits  enjoying  special  laxative  properties  include:  ap- 
ples, oranges,  peaches,  cherries,  prunes,  and  plums.  Among 
the  fruits  combining  both  of  the  above  advantages  are : 
prunes,  raisins,  figs,  and  apples. 

Where  acid  fermentation  results  from  the  ingestion  of  raw 
fruit,  then  stewed  fruit  becomes  a  useful  and  an  agreeable 
addition  to  the  dietan,'.  The  only  objection  that  may  be 
raised  against  partaking  of  stewed  fruit  is  that  so  much  sugar 
is  required  in  its  preparation  as  to  disorder  the  stomach  and 
provoke  flatulency.  Canned  and  preserved  fruits  are  of  little 
value.     Bananas  are  constipating. 

The  patient  should  take  many  draughts  of  water  during 
the  course  of  the  day.  AYater  may  be  taken  ziitJi  meals ;  the 
statement  offered  that  the  liquid  dilutes  the  gastric  juice  and 
thus  interferes  with  gastric  digestion  has  no  basis  in  fact;  per 
contra,  the  addition  of  water  to  the  gastric  juice  does  not 
maLerially  dilute  that  powerful  acid  secretion,  but  rather  in- 
creases its  quantitv  for  action  upon  various  foods  concerned 
in  stomachic  digestion. 


CONSTIPATION.  857 

Persons  of  a  constipated  tendency  should  avoid  eggs,  milk, 
sweets,  fried  foods,  gravies,  sauces,  strong  condiments,  pickles, 
tea,  and  sour  and  red  wines. 

The  medical  treatment  of  constipation  often  becomes  a 
necessary  evil.  It  should  always  be  regarded  as  a  last  resort. 
The  broad  rules  to  be.  followed  in  the  use  of  drugs  may  be 
tabulated  as  follows : 

1.  Use  laxative  drugs  only  after  other  measures  have 
failed. 

2.  Their  use  should  be  continued  daily  in- small  doses  until 
the  stool  becomes  soft. 

3.  DrugS'  should  be  changed  or  alternated  so  that,  the 
bowels  do  not  become  accustomed  to  any  particular  remedy, 
thus  engendering  constipation. 

Laxative  drugs  include  the  salines  and  vegetable  laxatives. 
The  salines  include,  besides  the  various  mineral  waters,  Ro- 
chelle,  Epsom,  Glauber's  salt,  and  the  citrate  of  magnesia. 
All  salines  should  be  given,  very  much  diluted,  the  first  thing 
in  the  morning  on  rising.  This  is  imperative,  because  saline 
laxatives  act  upon  the  empty  bowel  and  favor  peristalsis  by 
abstracting  the  watery  elements  from  the  intestinal  blood- 
vessels. Among  the  many  vegetable  laxatives  is  mentioned 
cascara,  compound  licorice  powder,  the  compound  cathartic 
pill,  U.  S.  P. ;  the  aloin,  belladonna,  strychnin,  cascara  pill, 
senna,  podophyllum,  and  rhubarb.  Each  of  these  drugs  pos- 
sesses certain  virtues,  and  may  or  may  not  be  adaptable  to 
every  case. 

In  atonic  conditions  of  the  intestines  it  is  frequently  advan- 
tageous to  combine  drug's  that  increase  peristalsis.  Thus, 
physostigma  is  a  stimulant  to  peristalsis  by  augmenting  mus- 
cular activity  in  the  intestinal  walls.  Plyoscyamus  and  bella- 
donna increase  peristalsis  by  a  depressing  action  on  the 
peripheral  ends  of  the  inhibitory  fibers  of  the  splanchnics  and 
by  decreasing  any  tendency  to  spasm  of  the  muscular  coat  of 
the  bowel.  Atropin  can  likewise  be  employed ;  while  strych- 
nin added  to  purgative  pills  avoids  the  depressing-  after-effects 
on  the  intestine.  The  rationale  of  ordering-  strychnin,  hyos- 
C3^amus,  and  physostigma  in  combination  with  cathartics  such 
as  aloin  or  podophyllum,  is  well  exemplified  in  mau}^  laxative 
pills.     A  combination  of  cathartics  often  relieves  the  harsh 


858  DISEASES    OF    THE   DIGESTIVE    SYSTEM. 

action  that  results  if  one  is  given  singly.  This  is  well  illus- 
trated in  the  well-known  compound  cathartic  pill,  U.  S.  P., 
composed  of  colocynth,  jalap,  gamboge,  and  calomel,  a  com- 
bination which  is  very  efficient  as  a  purge,  and  unattended 
with  much  griping.  Eserin  acts  as  a  stimulant  to  the  mus- 
cular coat  of  the  bowel,  and  is  especially  valuable  in  elderly 
persons  and  others  whose  intestinal  muscular  fibers  are  failing 
in  power.     The  average  dose  is  %o  of  a  grain  (0.00216  Gm.). 

Ordinarily,  it  is  best  to  give  vegetable  laxatives  at  bed- 
time, because  some  hours  are  required  for  their  action.  In 
cases  of  obstinate  constipation,  good  results  are  often  attained 
by  administering  the  vegetable  laxatives  after  each  meal.  The 
use  of  liquid  petroleum  products  have  received  a  measure  of 
approbation  because  of  the  lubricating  action  which  they  have 
upon  the  intestinal  contents,  in  this  way  favoring  peristalsis. 

Mechanical  measures  include  the  use  of  enemata  and  sup- 
positories. Their  employment  may  be  resorted  to  as  an  oc- 
casional substitute  for  laxatives.  They  act  upon  the  rectum 
and  the  lower  colon,  but  their  use  is  limited  since  they  soon 
obtund  the  sensibility  of  the  rectum.  When  the  action  of  the 
laxative  medicine  fails  to  assert  itself,  or  if  the  stomach  is 
unretentive,  the  use  of  a  suppository  or  enema  may  be  substi- 
tuted. Massage,  stimulating  the  abdominal  muscles  and  peri- 
stalsis, may  be  practiced  at  regular  periods  during  the  day  and 
at  times  corresponding  to  that  of  desired  evacuations.  The 
abdominal  muscles  and  peristalsis  are  stimulated  in  this  way. 
The  rolling  of  a  heavy  ball  or  cannon  ball  along  the  course 
of  the  large  intestine  is  often  effective.  In  the  obese  and  per- 
sons with  pendulous  abdomens,  as  is  seen  among  women  who 
have  borne  many  children,  the  adjustment  of  a  suitable  belt 
or  tight  binder  will  not  infrequently  act  as  an  important  ad- 
junct in  treatment. 

In  cases  of  impacted  feces  much  difficulty  is  often  experi- 
enced in  moving  the  bowels.  All  irritating  measures  should 
be  avoided,  especially  drastic  cathartics.  Saline  laxatives  are 
well  adapted  for  this  purpose,  as  are  combinations  of  vege- 
table drugs.  Another  useful  laxative  agent  is  the  infusum 
sennse  compositum,  U.  S.  P.,  4  ounces  (120  mils)  at  a  dose. 
This  is  commonly  designated  "Black  Draught,"  and  is  com- 
posed of  senna,  manna,  and  sulphate  of  magnesium.     When 


INTESTINAL  OBSTRUCTION.  859 

a  hard  inspissated  fecal  accumulation  can  be  felt  in  or  above 
the  rectum,  it  may  become  necessary  to  remove  it  with  the 
finger,  aided  by  a  spoon  or  other  device  employed  for  this  pur- 
pose. Rectal  injections  forced  beyond  the  seat  of  impaction 
may  prove  efficient  in  removing  the  hardened  feces.  These 
should  be  given  hot  to  act  as  a  solvent  on  the  fecal  accumula- 
tion. Only  part  of  the  mass  should  be  removed  at  a  time  to 
prevent  irritation. 

INTESTINAL    OBSTRUCTION. 

Intestinal  obstruction,  a  condition  which  arises  when  the 
fecal  current  is  impeded  or  prevented,  may  be  incomplete  or 
complete,  acute  or  chronic.  Acute  obstruction  is  due  to  a 
sudden  occlusion  of  the  gut,  while  in  chronic  obstruction  the 
narrowing  of  the  lumen  is  gradual,  but  obstruction  is  likely 
to  become  acute  at  any  time.  The  acute  variety  is  most  com- 
mon in  the  small  intestine ;  the  chronic  form,  in  the  large  gut. 
It  is  the  chronic  form  that  occurs  most  frequently  in  the  aged. 

Intestinal  obstructions  may  be  classified  as  follows : 

Strangulation.  This  is  the  most  common  form,  and  is  usually 
due  to  peritoneal  adhesions.  Constriction  of  a  loop  of  intes- 
tine may  be  caused  by  the  free  end  of  a  persistent  Meckel's 
diverticulum  attached  to  the  abdominal  wall. 

Strangulation  may  also  take  place  beneath  an  adherent  ap- 
pendix, a  fallopian  tube,  or  a  portion  of  mesentery.  This  form 
of  obstruction  is  identical  with  that  occurring  in  hernia.  Seventy 
per  cent,  of  the  cases  of  strangulation  occur  in  males,  and  40  per 
cent,  in  persons  between  the  ages  of  15  and  30. 

Volvulus  or  tzvists  in  the  intestine  are  most  common  at  the 
'sigmoid  flexure  of  the  colon.  An  unusually  long  or  lax  mes- 
entery is  a  predisposing  factor.  A  twist  with  a  sharp  bend  in  the 
bowel  results  in  strangulation.  Males  between  40  and  60  are 
especially  prone  to  the  condition. 

Intussusception  is  due  to  active  peristalsis,  and  is  tlie  form 
of  obstruction  mostly  always  found  in  children.  It  occurs  at 
the  ileocecal  valve,  in  the  ileum  or  cecum,  and  occasionally  in 
the  rectum.  It  may  be  described  as  a  telescoping  of  one  sec- 
tion of  the  bowel  into  another.  More  than  50  per  cent,  of  the 
subjects  thus  affected  are  under  10  years  of  age. 


860  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

Among  the  other  causes  of  obstruction  are :  intestinal 
stricture,  either  cicatricial  or  malignant,  obstruction  by  tumors 
inside  or  outside  of  the  bowels,  by  foreign  bodies  (gall-stones, 
enteroliths,  intestinal  calculi)  and  fecal  accumulations.  The 
latter  are  due  to  paresis  or  paralysis  of  the  gut. 

In  acute  obstruction  of  the  bowels  pain  comes  on  suddenly, 
and  is  severe  and  colicky,  accompanied  by  syncope,  extreme 
prostration  and  shock.  Vomiting  is  an  early  symptom.  First 
the  stomach  contents  are  ejected,  followed  later  by  bilious 
vomiting,  and  finally  the  regurgitated  matter  is  stercoraceous. 
The  abdomen  is  tense,  distended  and  tender.  As  shock  passes 
off,  the  temperature  becomes  elevated ;  but  in  an  unrelieved 
case  there  is  a  subnormal  temperature,  a  cool,  clammy  skin, 
and  a  rapid,  feeble  pulse.  The  tongue  is  uncoated,  the  mind 
lucid,  and  muscular  cramps  are  not  uncommon.  Constipation 
is  absolute,  not  even  flatus  being  passed.  True  fecal  vomiting 
does  not  occur  when  the  obstruction  is  in  the  upper  third  of 
the  ileum,  and  when  high  up  in  the  small  intestine  tympanites 
does  not  occur.  The  quantity  of  urine  passed  is  much 
decreased. 

In  chronic  intestinal  obstruction  there  is  gradual  narrowing 
of  the  lumen  of  the  intestine,  increasing  difficulty  in  securing 
a  bowel  movement  by  the  use  of  laxatives,  persistent  diarrhea, 
which  is  the  result  of  a  catarrhal  inflammation  above  the  seat 
of  constriction,  colicky  pains  produced  by  increased  peristal- 
sis, pronounced  tympanites,  and  vomiting. 

The  causes  of  chronic  obstruction  include  malignant  disease  at 
or  below  the  ileocecal  valve,  cicatricial  narrowing  affecting  the 
same  portion  of  the  bowel,  and  chronic  slowly-progressing 
invagination.  In  chronic  obstruction  there  are  intervals  be- 
tween the  attacks  of  pain,  the  exacerbations  gradually  becom- 
ing more  frequent  and  severe.  Vomiting,  though  not  of  the 
stercoraceous  type,  occurs,  and  the  bowel  movements  are  in- 
effective. In  the  intervals  between  these  seizures  the  patient 
complains  of  dyspeptic  symptoms,  suffers  abdominal  disten- 
tion, and  the  attacks  of  constipation  alternate  with  diarrhea. 

These  attacks  recur  with  increasing  frequency.  The  patient 
loses  flesh  and  strength,  and  may  develop  marked  S3^mptoms 
of  acute  obstruction.  The  subject  becomes  so  emaciated  that 
the  distended  coils  of  bowel  may  be  seen  beneath  the  wall  of 


INTESTINAL  OBSTRUCTION.  861 

the  abdomen.  Jjorborygmi  or  bowel  noises  are  common. 
Death  may  be  caused  by  progressive  exhaustion  from  a  super- 
vening- acute  obstruction. 

TREATMENT. 

If  the  diagnosis  is  somewhat  doubtful,  and  the  patient  ap- 
pears shocked,  a  stimulant  should  be  administered,  a  hot  water 
enema  given,  and  external  heat  applied.  In  acute  obstruction 
empty  the  stomach  by  lavage,  and  the  bowel  by  large  injec- 
tions of  warm  soap  water.  In  acute  intussusception,  give  no 
food  by  the  mouth.  The  bowels  should  be  kept  immobile  with 
large  doses  of  opium  or  of  opium  and  belladonna  in  the  form  of 
suppositories.  If  the  intussuscepted  intestine  cannot  be  with- 
drawn because  of  adhesions,  the  patient  should  be  etherized, 
placed  in  an  inverted  position,  and  warm  saline  solutions  of  oil  in- 
jected by  means  of  a  fountain  syringe,  the  nozzle  being  in- 
serted up  as  far  as  the  sigmoid  flexure  of  the  colon. 

At  this  time  with  the  intestines  full  of  liquid,  the  abdomen 
should  be  compressed,  care  being  taken  not  to  exert  undue 
pressure.  If  this  maneuver  proves  unsuccessful  the  intestines 
should  be  inflated  by  means  of  a  large  indiarubber  bag  con- 
taining air  or  hydrogen  gas,  of  which  2  or  3  gallons  may  be 
cautiously  introduced.  In  cases  of  intussusception  or  strangu- 
lation of  the  bowels  these  efiforts  must  be  persisted  in  for 
twenty-four  hours.  If  the  condition  is  not  relieved  the  case 
should  pass  into  the  hands  of  the  surgeon.  There  is  a  division 
of  opinion  in  the  profession  concerning  the  advisability  of  in- 
troducing a  fine  trocar  and  cannula  to  allow  of  the  escape  of 
gas  from  the  tympanitic  abdomen.  Many  experienced  surgeons 
regard  this  procedure  in  minor  surgery  as  a  very  dangerous 
expedient.  In  the  statistical  table  collected  by  the  late  Dr. 
Reginald  H.  Fitz,  69  per  cent,  of  the  cases  of  intestinal  ob- 
struction without  laparotomy  proved  fatal ;  with  operation, 
83  per  cent.  Undoubtedly  the  high  mortality  rate  under  oper- 
ation can  be  explained  by  the  fact  that  in  many  of  these  in- 
1  stances  surgical  interference  was  deferred  too  long. 

The  operation  if  performed  at  all  should  not  be  postponed 
longer  than  twenty-four  hours.  Pain  is  to  be  relieved  by 
morphin,  and  the  incessant  vomiting  is  best  met  by  gastric 
lavage  and  the  withholding  of  food  for  some  hours  to  prevent 


862  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

retching  and  aggravation  of  the  symptoms.  Gastric  lavage 
may  be  practised  every  six  hours.  Cathartics  are  absolutely 
contraindicated  in  acute  intestinal  obstruction. 

In  chronic  obstruction  treatment  is  to  be  conducted  on 
general  principles.  The  bowels  should  be  moved  with  simple, 
unirritating  laxatives,  and  due  attention  paid  to  the  dietary. 
When  there  is  threatened  obstruction,  with  pain,  the  treatment 
just  advised  for  acute  obstruction  of  the  bowels  should  be 
followed.  (See  p.  861.)  The  after-treatment  consists  in  regu- 
lation of  the  bowels,  by  habit,  diet,  and  aperients,  as  detailed 
on  the  chapter  on  Constipation  (q.  v.).  The  employment  of 
massage  and  electricity,  in  conjunction  with  other  measures 
that  may  suggest  themselves  to  the  intelligent  practitioner, 
may  prove  to  be  valuable  adjuncts  of  treatment. 

ENTEROPTOSIS;    VISCEROPTOSIS; 
SPLANCHNOPTOSIS. 

The  term  enteroptosis  from  an  etymologic  standpoint  sig- 
nifies a  falling  or  ptosis  of  the  intestines,  but  the  condition  is 
of  such  frequent  occurrence  coincidently  with  gastroptosis, 
nephroptosis,  and  prolapse  of  other  viscera,  including  the 
spleen,  liver,  and  uterus,  that  the  term  visceroptosis,  splanch- 
noptosis (Glenard's  disease),  and  enteroptosis  are  employed 
synonymously. 

In  1885,  Glenard  published  a  monograph  that  attracted 
wide  attention  and  invited  thought  from  the  elite  of  science ; 
in  it  he  set  forth  his  views  upon  enteroptosis,  and  connected 
therewith  certain  nervous  phenomena  which  have  since  borne 
the  name  of  "Glenard's  disease."  This  masterly  article  and 
those  that  followed  by  the  same  writer  were  widely  discussed 
and  commented  upon,  partly  because  of  the  author's  earnest 
enthusiam  and  optimism. ^^ 

*T  can  affirm,"  declared  Glenard,  "that  the  physician  w^ho 
will  follow  my  directions  and  strive  to  verify  my  statements 
in  such  cases  will  find  in  his  practice  the  satisfaction  which  a 
positive  diagnosis  gives  to  both  physician  and  patient,  from 
which  alone  a  proper  prognosis  can  be  made,  and  that  satis- 
faction, the  greatest  of  all,  which  directs  the  treatment  and 
avoids  for  the  patient  the  trial  upon  him  of  so  many  remedies, 


ENTEROPTOSIS.  863 

while  at  the  same  time  it  secures  him  relief  and  prevents  the 
physician  himself  from  falling  into  therapeutic  scepticism." 
It  is  an  axiomatic  saying  in  medicine  that  to  cure  the  malady 
we  need  seek  the  cause  and  attack  it.  But  the  theory  that 
accounts  for  the  occasion  of  visceral  ptosis  is  yet  to  be 
pronounced. 

Years  ago,  Stiller  declared  it  to  be  a  congenital  anomaly. 
Schwerdt  believed  it  to  be  a  constitutional  malady;  an  atonic 
condition  of  the  neuromuscular  system.  JMeinert,  of  Dresden, 
ascribed  the  condition  to  mechanical  causes,  and  unhesitatingly 
declared  the  ill-fitting  corset,  the  constricting  waist-band,  and 
other  defects  of  dress,  especially  among  women,  to  be  instru- 
mental in  the  production  of  the  condition.  Charcot  regarded 
the  etiologic  factor  the  result  of  neurasthenia.  Sir  Frederick 
Treves  offered  these  theories :  Rapid  emaciation  or  severe  ill- 
ness may  cause  visceroptosis ;  or  it  may  be  engendered  by 
heavy  lifting  or  frequent  pregnancies,  thereb}^  weakening  the 
abdominal  walls  and  causing  a  descent  of  the  viscera;  or  that 
peritoneal  adhesions,  by  their  contracting  action  might  pull 
down  one  organ  after  another.  Rosengart  regards  visceropto- 
sis as  a  reversion  to  the  fetal  or  embryonic  type ;  and  the 
elaborate  and  conscientious  study  of  Arthur  Keith  regards  the 
condition  as  "a  result  of  vitiated  method  of  respiration,"  and 
he  places  this  complicated  entity  in  the  category  of  respiratory 
affections. 

Each  of  these  etiologic  factors  is  applicable  to  a  number  of 
cases.  The  theory,  as  advanced  by  Keith,  supposes  that  a 
faulty  mechanism  of  the  diaphragm  dependent  upon  many  con- 
ditions to  be  the  cause  of  visceral  ptosis,  for  it  is  a  physiolog- 
ical fact  that  normally  the  relations  of  the  muscles  of  inspira- 
tion to  those  of  expiration,  and  the  muscular  action  of  the 
abdominal  wall  in  no  way  cause  or  affect,  to  the  slightest  de- 
gree, a  displacement  of  the  viscera.  Keith  emphasizes  the 
fact  that  if  the  integrity  of  the  diaphragm  is  at  all  impaired, 
inspiratory  downward  displacement  is  instrumental  in  bring- 
ing about  visceral  ptosis,  especially  contraction  of  the  dia- 
phragmatic crura ;  asserting  that  although  the  supports  of  the 
diaphragm  are  three-fold — abdominal,  costal  and  thoracic — that 
derived  from  the  abdomen,  the  muscles  of  expiration,  is  the 
most  essential  to  the  production  of  the  condition. 


864  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

Decrease  of  the  sub-diaphragmatic  space  accounts  for  dis- 
placement of  the  kidney.  This  may  be  occasioned  by  con- 
striction of  the  thorax  from  faulty  dress;  from  deformity  and 
narrowing  of  the  chest  by  thoracic  or  spinal  disease  or  perma- 
nent contraction  of  the  diaphragm  from  a  relaxed  condition 
of  the  abdominal  wall.  The  left  kidney  is  not  so  often  dis- 
placed as  the  right,  because  "the  left  hypochondrium  is  pro- 
vided with  a  safety  valve  in  the  shape  of  the  splenic  flexure  of 
the  colon" ;  so  that  when  the  sub-diaphragmatic  space  is  de- 
creased, "the  colon  is  extruded  and  the  other  org^ans  are  un- 
disturbed." Ptosis  of  the  kidney  is  also  largely  prevented  by 
the  fact  that  there  are  intimate  attachments  between  the  kid- 
ney and  spleen,  and  the  spleen  and  diaphragm.  Prolapse  of 
the  colon,  according  to  Meinert,  is  more  frequent  than  gastrop- 
tosis ;  the  transverse  portion,  being  the  most  movable,  is  most 
often  displaced.  It  may  become  elongated  and  tortuous,  S-  or 
M-shaped,  or  found  lying  immediately  above  the  pubic  sym- 
physis. 

A  marked  degree  of  visceroptosis  may  exist  without  the 
presence  of  symptoms.  Usually,  however,  the  patient  com- 
plains of  digestive  disturbances.  He  has  a  sense  of  fullness 
after  eating,  complains  of  spasmodic  pain  and  flatulence,  and 
vomiting  may  supervene;  as  a  rule  the  sufferer  is  constipated, 
but  diarrhea  may  alternate  with  constipation.  When  gastrop- 
tosis  and  nephroptosis  are  associated,  the  patient  frequently 
becomes  neurasthenic,  is  irritable,  loses  flesh  and  strength, 
and  has  no  interest  in  life.  Car  sickness  and  train  sickness 
are  common  symptoms  of  real  moment. 

Undoubtedly  the  largest  number  of  cases  is  found  in 
women,  supporting  the  theory  advanced  by  Meinert  {q.  v.), 
and  which  has  been  ironically  expressed  by  the  gifted  writer 
of  "Gates  Ajar,"  in  her  conscientious  efforts  to  emancipate  her 
sex  "from  corsets  that  embrace  the  waist  with  a  tighter  and 
steadier  grip  than  any  lover's  arm,  and  skirts  that  weight  the 
hips  with  heavier  than  maternal  burdens." 

Persons  who  are  the  victims  of  visceral  ptosis  do  not,  as  a 
rule,  include  those  that  are  fair,  fat,  and  forty,  but  rather  those 
of  a  "lean"  habit,  tall  and  scrawny,  with  no  compactness  of 
form,  the  possessors  of  a  sad  and  doleful  expression,  indicative 
of   a   "neurasthenia   basis" ;   and   Keith   invites    attention   to   a 


ENTEROPTOSIS.  '  865 

peculiar  curving-   of  the   cervical   region,   to   which    he   aptly 
applies  the  term  "ewe's  neck." 

In  a  brief  exposition  of  an  important  condition  such  as  this, 
one  is  only  able  to  touch  upon  its  chief  diagnostic  signs.  Suf- 
fice it  to  say  that  when  a  patient  presents  himself,  or  herself, 
for  an  expression  of  medical  opinion,  a  diagnosis  of  enterop- 
tosis,  or  what  in  reality  is  the  same,  visceroptosis,  can  be  quite 
well  established  when  the  following  symptom-complex  is 
evidenced.  Digestive  disturbances  (which  may  not  amount 
to  actual  pain)  both  upon  arising  in  the  morning  and  when 
changing  from  a  recnmbent  to  a  standing  attitude,  a  "drag- 
ging" under  the  right  costal  cartilage,  a  "giving-way"  sensa- 
tion complained  of  when  the  patient  turns  in  bed  upon  the 
left  side,  constipation,  lack  of  ambition,  and  neurasthenic 
symptoms,  especially  in  those  of  a  lean  habit  and  of  the  female 
sex. 

In  all  of  these  cases  an  examination  of  the  abdomen  is  im- 
perative. The  topography  of  the  stomach  is  to  be  studied  by 
inflating  it  with  bicarbonate  of  soda  and  tartaric  acid  or  by 
air.  The  solid  organs  should  be  outlined,  care  being  taken  to 
examine  the  liver  in  the  standing  position,  since  this  organ  is 
far  more  often  displaced  than  is  generally  supposed. 

Glenard,  in  his  elaborate  studies,  mentions  a  small  band  that 
runs  across  the  abdomen,  about  2  inches  (5  cm.)  above  the 
navel,  and  is  plainly  discernible  to  the  palpating  fingers ;  to  it 
he  applied  the  term  "la  corde  colique  transverse,"  and  re- 
garded it  as  the  "colon  transversum."  But  there  is  good 
reason  to  doubt  the  correctness  of  this  inference,  and  Boas, 
Ziemssen  and  Ewald  assert  that  the  cord  is  the  pancreas, 
rendered  palpable  by  the  sinking  of  the  stomach.  In  palpat- 
ing the  abdomen  Glenard  lays  stress  upon  the  following  im- 
portant test :  The  patient  assumes  a  standing  attitude,  and 
the  physician  stands  behind  him.  The  examiner  places  both 
hands  flatly  over  the  lower  part  of  the  belly  and  applies  even 
pressure  upward  and  backward.  In  a  large  number  of  these 
cases  much  relief  is  experienced  from  the  distressing  dragging 
sensations  felt  in  the  epigastrium  and  abdomen.  X-ray  and 
fluoroscope  examination  confirm  the  diagnosis. 


55 


866  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

TREATMENT. 

If  there  is  a  discoverable  cause  producing  or  aggravating 
the  displacement,  it  should,  if  practicable,  be  removed.  Treat- 
ment will  be  most  efficient  that  will  meet  all  these  conditions 
by  the  restoration  of  bodily  vigor  and  by  upbuilding  of  the 
Avhole  musculature.  For  these  purposes  the  bowels  must  be 
moved  regularly,  the  tonicity  of  the  abdominal  walls  must  be 
increased  b}^  massage,  electricity,  and  h3'drotherapy.  In  cases 
of  neurasthenia  appropriate  measures  must  be  instituted,  in- 
cluding the  rest  cure.  (See  vol.  i,  p.  583.)  The  food  should  be 
nutritious  and  easily  digestible.  At  times,  the  employment 
of  gastric  lavage  acts  as  an  excellent  auxiliar}^  to  treatment. 
Drugs  are  demanded  to  combat  the  flatulency  and  fermenta- 
tion that  are  invariably  present,  and  the  administration  of 
tonics,  as  iron,  strychnin,  arsenic,  and  quinin  are  indispensable 
to  the  routine  of  treatment.  Belts  and  supports  are  useful 
only  when  they  relieve  the  intra-abdominal  pressure.  By 
their  supporting  action  they  encircle  the  abdomen  and, exert 
uniform  pressure  over  the  whole  abdominal  surface.  The 
much  vaunted  devices  advertised  to  hold  a  kidney  or  stomach 
in  place,  all  are  to  be  avoided  as  harmful  rather  than  helpful. 
Autointoxication  may  be  largely  prevented  by  a  milk  and 
buttermilk  diet. 

The  indications  for  treatment  as  outlined  by  Glenard  are 
as  applicable  today  as  when  first  pronounced. 

(a)  The  intestines  must  be  elevated  and  kept  in  their  new 
position. 

(b)  The  abdominal  pressure  must  be  increased. 

(c)  The  bowels  must  be  regulated. 

(d)  The  secretions  of  the  intestinal  glands  must  be  in- 
creased. 

(e)  The  digestion  and  nutrition  must  be  regulated  and 
stimulated. 

(/)   The  Avhole  organism  must  be  strengthened. 

The  anchoring  of  the  kidney,  pleating-  the  stomach  and 
gastrocolic  omentum,  and  other  measures  of  raising  the  ptosed 
organs  may  be  considered  in  suitable  cases. 


INTESTINAL  NEUROSES.  867 

INTESTINAL    NEUROSES. 

Secretory  Disturbances.  Through  a  nervous  influence  the 
intestinal  secretion  may  be  greatly  increased  in  quantity. 
Clinically,  this  abnormal  secretion  may  manifest  itself  as  a 
mucous  colic  or  a  pseudomembranous  enteritis.  The  latter 
subject  has  been  fully  discussed  under  the  caption  of  Mucous 
Colitis.     (See  p.  845.) 

Enteralgia.  Enteralgia  or  neuralgia  of  the  intestines  is 
commonly  encountered  in  hysterical,  neurasthenic,  or  anemic 
individuals.  It  occurs  as  a  reflex  neurosis  in  gout  and  in  irri- 
tative lesions  of  the  liver  and  kidneys.  It  may  be  a  symptom 
of  many  affections  causing  direct  irritation  of  the  sensory 
nerves  of  the  intestines.  These  include  foreign  bodies,  gall- 
stones, enteroliths,  and  marked  gaseous  distention,  so  that 
there  is  increased  activity  of  the  motor  nerves,  or  contraction 
of  the  muscularis,  engendering  true  intestinal  colic. 

Enteralgia  may  occur  suddenly,  but  more  often  gradually, 
and  is  attended  w^ith  much  flatulence.  As  the  attack  is  fully 
developed,  the  pain,  which  is  circumscribed  or  diffuse,  becomes 
almost  unbearable,  and  may  subside  quite  suddenly.  At  other 
times  these  pains  persist  for  days  or  weeks,  and  then  grad- 
ually vanish.  Recurrences  are  common,  but  the  intervals  be- 
tween the  attacks  vary  greatly  in  duration. 

Hypogastric  neuralgia  is  a  term  applied  to  a  painful  con- 
dition encountered  most  often  in  the  female  sex,  and  in  those 
of  a  neurotic  constitution.  It  also  frequently  occurs  in  cases 
of  tabes  and  in  hemorrhoids.  This  affection  has  its  seat  in  the 
hypogastrium,  and  provokes  distressing  pressure-symptoms  in 
the  bladder  and  rectum,  the  pains  radiating  to  the  sacrum, 
thighs,  and  perineum. 

Diminished  Intestinal  Sensibility.  This  condition  is  found 
quite  commonly  in  affections  of  the  brain  and  spinal  cord  asso- 
ciated with  paralysis.  There  is  a  decrease  of  peristaltic  move- 
ments, with  more  or  less  anesthesia  of  the  bowels,  and  a  con- 
sequent retention  of  fecal  accumulations  in  the  rectum.  When 
the  integrity  of  the  motor  mechanism  of  the  bowel  is  not 
interfered  with,  and  the  musculature  of  the  intestines  pre- 
serves its  power  of  contraction,  spontaneous  movements  of  the 
bowels  occur;  but  when  an  atonic  condition  exists,  the  result 


868  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

of  motor  paralysis,  the  fecal  accumulations  must  be  removed 
by  mechanical  means. 

Nervous  Diarrhea.  Increased  irritability  of  the  motor 
nerves  of  the  bowels  results  in  diarrhea.  The  condition  may 
be  reflex  to  morbid  conditions  in  the  central  nervous  system 
or  some  remote  organ  of  the  body.  Thus,  the  affection  may 
be  traced  to  factors  such  as  tabes,  certain  g-astric  disturbances, 
and  dentition.  It  is  not  infrequently  found  in  persons  of  an 
unstable  nervous  organization,  who  suffer  sudden  fright, 
shock,  or  surprise.  The  only  characteristic  symptoms  pres- 
ent are  the  number  of  dejections,  which  may  vary  from  two 
or  three  to  as  many  as  thirty  in  the  course  of  the  da^".  The 
stools  follow  each  other  in  rapid  succession,  especially  during 
the  morning  hours.     There  are  no  other  constant  symptoms. 

Enterospasm.  Spasm  of  the  intestine  usually  induces  spas- 
modic constipation,  and  at  times  total,  though  temporar}% 
occlusion  of  the  bowels.  The  etiologic  factors  concerned  in  its 
production  are  quite  analogous  to  those  causing  nervous  diar- 
rhea, and  clinically  it  oft'ers  a  study  essentialh^  the  same  as 
that  of  enteralgia.  Pain  or  constipation  is  an  inconstant  symp- 
tom, the  stools  may  or  may  not  be  ribbon-shaped,  or  the  pa- 
tient discharges  large  round  fecal  masses,  comparable  to 
sheep's  dung.  The  dejecta  may  be  covered  with  mucus. 
Proctospasm  is  usually  secondary  to  fissure  or  some  other 
rectal  affection.  In  neurasthenic  subjects,  enterospasm  may 
manifest  itself  as  a  neurosis. 

Constipation.  As  a  functional  neurosis,  constipation  is 
often  found  in  those  suft'ering  from  neurasthenia  or  hysteria, 
and  in  victims  of  various  forms  of  psychoses.  Ewald  states 
that  these  patients  are  not  influenced  by  the  administration  of 
cathartics.  Paralysis  of  the  external  sphincter  is  not  infre- 
quently associated  with  diseases  of  the  central  nerv'ous  system, 
in  which  event  the  dejecta  are  passed  reflexly,  due  to  loss  of 
innen-ation  of  the  voluntary  muscles,  or  the  act  may  be 
voluntar}'  but  not  purposeful,  as  during  mental  excitement, 
sneezing,  or  coughing,  demonstrating-  merely  a  condition  of 
bodily  weakness. 

TREATMENT. 

In  all  these  cases  the  best  possible  h}'gienic  environment 
and  a  suitable  dietary  are  to  be  regarded  as  more  than  stereo- 


CARCINOMA  OF  THE  INTESTINE.  869 

typed  text-book  suggestions.  The  treatment  of  special  cases 
takes  into  account  the  nature  of  the  underlying  nervous  affec- 
tion and  of  any  pathologic  entity  provoking  the  condition,  and 
these  need  be  vigorously  combated. 

In  enteralgia  and  hypogastric  neuralgia  the  treatment  con- 
sists in  relieving  the  painful  paroxysms  by  the  use  of  mor- 
phin  or  opium,  by  the  application  of  heat  in  some  of  its  many 
forms ;  and  in  the  intervals  in  attending  to  the  alimentary  and 
digestive  functions,  the  administration  of  tonics,  and,  if  need 
be,  a  change  of  residence.  It  is  asserted  by  some  clinicians 
that  a  combination  of  drugs  such  as  quinin  (alterative)  and 
belladonna  (antispasmodic)  is  most  effective  treatment  in  the 
intervals  of  the  attack,  and  often  exerts  a  curative  action. 
Surely,  if  such  is  a  fact,  the  administration  of  this  combina- 
tion of  drugs  should  merit  a  trial. 

In  cases  of  constipation  dependent  upon  diminished  sensi- 
bility and  atony  of  the  bowel,  unless  the  cause  of  the  com- 
plaint can  be  located  and  treated,  the  fecal  accumulations 
must  be  removed  mechanically. 

In  the  treatment  of  nervous  diarrhea,  the  exhibition  of  the 
usual  medicaments  as  used  in  the  ordinary  loose  dejections 
of  enteritis  is  contraindicated.  The  objects  in  treatment  are, 
first,  to  relieve  pain  by  the  use  of  the  usual  anodynes;  second, 
the  correction  of  the  causes  on  which  the  attack  depends.  The 
large  serous  discharges  that  are  likely  to  occur  as  the  result 
of  anxiety  or  other  emotions  are  best  met  by  prescriptions 
containing  camphor,  chloroform,  and  the  volatile  oils.  All 
active  exercise  must  be  interdicted.  Heat  may  be  applied  to  the 
abdomen,  and  the  food  should  be  restricted  to  broths  or  milk 
foods.  When  the  number  of  stools  passed  is  large  the  patient 
should  take  to  bed.  The  treatment  of  enterospasm  is  identical 
with  that  of  enteralgia  (q.  z'.). 

CARCINOMA    OF   THE    INTESTINE. 

This  is  a  very  common  cause  of  intestinal  obstruction.  It 
is  more  common  in  men  and  in  persons  over  the  age  of  fifty. 
The  etiologic  factor  in  very  many  instances  is  dependent  upon 
the  local  irritation  produced  by  the  friction  of  the  fecal  mass 
against    the    intestinal    walls,    and    finds    corroboration    in    the 


870  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

Study  of  statistics  of  diseases  of  the  large  intestine,  where  80 
per  cent,  of  cases  of  cancer  have  been  found  in  the  rectum, 
the  remaining  20  per  cent,  distributed  in  the  cecum,  and  in  the 
sigmoid,  splenic,  and  hepatic  flexures  of  the  colon. 

Cancer  of  the  bowel  may  exist  for  some  time  without  sug- 
gestive symptoms  directly  referable  to  the  intestine  until 
ulceration,  stricture,  or  tumor  is  manifest.  Previous  to  this, 
and  extending  possibly  over  a  long  period  of  time,  the  patients 
bowels  have  been  "irregular."  Later  there  is  a  sense  of  dis- 
comfort, but  as  the  condition  progresses  this  discomfort  as- 
serts itself  in  the  form  of  colick}-  pains,  which  gradually 
increase  in  intensity.  When  the  rectum  is  invaded,  the  char- 
acteristic tenesmus  is  a  cardinal  symptom. 

The  patient's  loss  of  flesh  and  strength  are  out  of  propor- 
tion to  the  suffering  experienced,  and  although  the  victim  of 
the  malady  may  have  a  normal  appetite  and  good  digestive 
powers,  the  resulting  cachexia  is  an  unfailing  sign  of  a  malig- 
nant onslaught  upon  his  vital  powers.  When  the  cancerous 
deposit  is  low  down  in  the  large  intestine  the  fecal  discharges 
conform  to  the  narrowed  caliber  of  the  tube,  and  are  ribbon- 
like or  furrowed,  and  blood  and  mucus,  as  well  as  portions  of 
tissue  and  pus,  may  be  made  out  both  by  macroscopic  and 
microscopic  investigation.  AMth  the  onset  of  these  phenom- 
ena, the  raw  and  bleeding  surface  of  the  bowel  occasions  con- 
tinuous diarrhea  and  intense  pains,  the  patient  suffers  marked 
exhaustion,  anorexia  asserts  itself,  the  dig'estive  powers  are 
impaired,  and  there  is  blanching  of  the  skin,  and  the  facial  ex- 
pression is  one  of  marked  anxiety. 

Late  in  the  aftection,  the  presence  of  a  visible  and  palpable 
tumor  is  part  of  the  course  of  this  fatal  invasion,  the  patient 
usually  not  sur^'iving  the  attack  longer  than  six  months  to  a 
year.  A  speedy  fatal  issue  follows  perforation,  which  at  times 
takes  place.  Death,  as  a  rule,  results  from  emaciation  and 
exhaustion,   with  edema  of  the  lungs  as  a  terminal  s}aiiptom. 

TREATMENT. 

From  a  strictly  medical  standpoint,  treatment  of  cancer  of 
the  intestines  is  absolutely  palliative.  The  diet  should  be  of 
the  most  nourishing  character  and  easily  digestible,  but  when 
symptoms  of  obstruction  assert  themselves  the  ingestion  of 


TUBERCULOSIS  OJ/  THE  INTESTINE.  871 

food  by  the  mouth  is  interdicted.  In  cases  of  duodenal  or 
jejunal  carcinomata,  nutrition  should  be  effected  by  means 
of  nutritive  enemata.  For  the  violent  pains  subcutaneous  in- 
jections of  morphin  and  also  opium  by  suppositories  should  be 
given.  Cannabis  indica,  with  or  without  opium,  is  often  pro- 
ductive of  good  results.  When  symptoms  of  marked  de- 
pression are  evidenced,  the  administration  of  stimulants  is 
demanded.  The  bowels  must  be  kept  in  a  soluble  condition 
by  laxatives  and  enemata,  and  lavage  of  the  stomach  offers 
great  relief  to  the  patient,  in  ridding  the  system  of  fermenting 
food,  which  not  infrequently  is  retained  in  the  stomach  or  re- 
gurgitated into  that  viscus.  If  there  are  evidences  that  a 
stricture  has  reached  an  advanced  stage,  the  irritating  action 
of  laxatives  of  all  kinds  had  better  be  dispensed  with,  and 
enemata  resorted  to,  as  the  action  of  aperients  may  cause  per- 
foration and  rupture.  Further  treatment  in  these  cases  be- 
longs to  the  domain  of  the  abdominal  surgeon. 

TUBERCULOSIS  OF  THE  INTESTINE. 

Next  to  the  lungs,  the  intestines  are  the  most  frequent  seat 
of  tuberculosis.  Chronic  diarrhea  is  a  cardinal  symptom  of 
the  disease,  often  alternating  with  temporary  periods  of  nor- 
mal movements,  or  even  with  constipation.  The  dejecta  vary 
in  color  according  to  the  drugs  that  have  been  given,  and  the 
ingesta  consumed,  and  are  extremely  feculent  and  slimy,  and 
may  contain  blood.  The  movements  of  the  bowels  often  are 
excited  by  food  or  drink,  the  discharges  being  preceded  by 
colicky  pains  that  are  relieved  by  evacuation.  Intestinal 
tuberculosis  as  the  primary  lesion  of  this  infection  is  far  more 
common  in  childhood  than  in  adults.  When  thus  affected  the 
child  appears  pale  and  wan  and  has  a  protruding  abdomen  as 
the  result  of  gaseous  distention.  The  little  one's  skin  is  harsh 
and  dry,  and  hangs  from  its  body  in  w^rinkles  and  folds,  giving 
It  the  appearance  of  a  withered  old* crone.  The  distended  belly 
usually  is  not  tender,  the  tension  being  relieved  by  the  escape 
of  gas,  at  which  time  the  mesenteric  glands  may  become 
visible.  The  lymphatic  glands  in  the  groin,  axillse,  and  neck 
may  become  enlarged. 

The  temperature  changes  conform  to  the  usual  character 


872  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

of  fever  in  tuberculosis,  and  during  the  exacerbations  profuse 
sweating,  especially  of  the  head  and  back,  is  commonly  ob- 
served. 

Secondary  tuberculosis  of  the  intestine  is  frequently  com- 
bined with  pulmonary  tuberculosis  in  both  3^oung  and  old. 
The  appearance  of  the  tubercle  bacillus  in  the  dejecta  is  not 
of  diagnostic  import,  because  of  the  frequency  with  which  the 
sputa  are  swallowed.  If  diarrhea  is  present  it  stubbornly  re- 
sists treatment,  and  it  should  be  remembered  that  this 
troublesome  symptom  may  be  produced  by  a  catarrhal  colitis 
or  amyloid  change,  both  of  which  processes  may  occur  in  the 
course  of  pulmonary  phthisis.  Abdominal  pain  is  usually  in- 
considerable, although  attacks  of  colic  occur.  The  abdomen 
is  retracted,  and  tender  spots  may  be  elicited  upon  pressure, 
showing  the  extension  of  the  ulcerative  process  toward  the 
peritoneal  surface  of  the  bowel.  The  chief  location  of  the 
infective  lesion  may  be  for  a  period  of  time  at  the  cecum  or 
in  the  appendix,  when  both  local  and  general  symptoms  of 
appendicitis  are  a  conspicuous  element  of  the  affection. 

TREATMENT. 

The  treatment  of  intestinal  tuberculosis  must  have  for  its 
basis  the  general  hygienic  management  and  the  treatment  as 
applied  to  cases  of  chronic  tuberculosis.  A  most  important 
factor  in  the  treatment  of  the  diarrhea  is  a  properly  restricted 
dietary.  Among  the  more  useful  medical  measures,  used 
singly  or  in  combination,  are  bismuth  in  large  doses,  acetate 
of  lead,  opium,  thymol,  salol,  silver  nitrate,  creasote,  and  chalk 
mixtures  containing  tannic  acid.  Externally,  turpentine 
stupes,  mild  counterirritation,  and  the  application  of  spice 
plasters,  often  afford  relief. 

SYPHILIS  OF  THE  INTESTINE. 

The  intestines  may  become  the  seat  of  syphilitic  lesions 
similar  to  those  affecting  other  mucous  surfaces.  Gummata, 
diffuse  infiltrations  of  the  intestinal  canal,  and  perforating 
ulcers  probably  due  to  gummata  have  been  diagnosed  and 
reported  by  many  clinicians  and  syphilographers. 

The  rectum  may  become  the  seat  of  a  series  of  important 


SYPHILIS  OF  THE  INTESTINE.  873 

changes  due  to  this  disease.  Women  are  more  prone  to  in- 
testinal syphiHs  than  men,  in  the  proportion  of  8  to  1.  This 
is  in  part  due  to  the  anatomic  differences  of  the  sexes,  to 
the  occurrence  of  the  menstrual  molimen  in  women,  to  pre- 
vious pregnancies,  and  to  unnatural  and  excessive  coitus. 

Care  must  be  taken  to  distinguish  between  the  induration 
of  the  submucous  tissues  about  the  rectum  with  purulent  san- 
g'uinolent  discharge  and  constipation  due  to  chancroids  and 
syphilitic  stricture  of  this  part  of  the  bowel.  The  most  im- 
portant syphilitic  affections  of  the  rectum  are  those  charac- 
terized by  ulceration  or  gummatous  changes ;  the  former  may 
extend  from  the  perineal  region  to  an  inch  (2.5  cm.)  or  more 
within  the  sphincter.  The  ano-rectal  syphiloma  is  a  non- 
ulcerative gaimmatous  infiltration  of  the  anus  and  the  walls 
of  the  rectum,  often  resulting  in  stricture,  the  result  of  trans- 
formation into  fibrous  tissue. 

TREATMENT. 

To  attempt  to  outline  the  treatment  of  this  special  form  of 
syphilis  would  be  a  work  of  supererogation,  for  the  manage- 
ment of  lues  has  been  described  elsewhere  in  minute  detail. 
(See  vol.  i,  p.  78,  et  seq.)  In  addition,  the  usual  hygienic 
measures  are  to  be  followed,  as  laid  down  in  the  treatment  of 
all  constitutional  ailments.  The  diet  should  be  nutritious,  at- 
tention paid  to  movements  of  the  bowels,  and  tonic  treatment 
administered  when  occasion  demands. 

Drug  medication  includes  inunctions  with  mercury,  the 
administration  of  mercury  and  chalk,  especially  in  children ; 
the  employment  of  mixed  treatment,  the  latter  often  combined 
with  one  of  the  forms  of  iron,  a  routine  followed  by  many 
excellent  practitioners,  who  assert  that  such  a  ferruginous  ad- 
dition prevents  the  development  of  stomatitis  and  salivation. 

In  place  of  the  administration  of  mixed  treatment,  many 
physicians  believe  in  the  efficiency  of  the  iodids  or  prepara- 
tions of  mercury  when  given  alone;  although  so  great  an 
authority  as  the  late  Prof.  J.  Wm.  White  and  a  large  follow- 
ing of  expert  syphilographers  emphatically  deny  the  pos- 
sibility of  curing  tertiary  syphilis  by  the  administration  of  the 
iodids  alone. 

Much  attention  has  been  given  in  recent  vears  to  the  intra- 


874  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

venous  injection  of  salvarsan  or  arsenobenzol,  and  also  of 
sodium  cacodylate,  by  the  intermuscular  route.  Advantage 
is  taken  of  the  injection  of  mercury  salicylate,  to  be  dissolved 
in  warm  water  and  given  intramuscularly  in  doses  of  0.065 
gram  (1  gr.)  ;  the  use  of  succinate  of  mercury  and  gray  oil 
may  supplement  these  procedures.  The  regulation  of  the  dose 
and  the  frequency  of  application  depend  upon  the  symptoms 
and  the  physiologic  effects  that  are  manifested.  From  time  to 
time  the  Wassermann  reaction  is  to  be  taken  as  a  corroborative 
measure  of  the  efficiency  of  the  medication  instituted. 


DISEASES  OF  THE  LIVER. 

GENERAL  CONSIDERATIONS. 

The  liver  may  be  rightly  considered  the  filtration  plant  of 
the  abdomen.  Its  circulation  is  such  that  the  hepatic  func- 
tion is  closely  related  to  all  of  the  abdominal  viscera.  Changes 
in  the  organs  may  be  accompanied  by  changes  in  the  liver  or 
vice  versa.  There  is  also  a  direct  relation  between  its  sym- 
pathetic supply  and  the  general  nervous  system,  which  when 
inco-ordinate  may  act  reflexly  upon  the  normal  functions  of 
the  liver.  Undue  nervous  excitement,  fatigue,  certain  indus- 
trial employments,  personal  habits,  intoxications,  infections, 
and  in  fact  any  physical,  chemical,  mechanical,  or  physiologic 
disturbance  of  the  body  may  affect  the  hepatic  functions. 
Disturbances  of  the  ear  and  of  the  eye  may  also  affect  this 
organ  indirectly. 

A  brief  discussion  of  the  anatomy  and  physiology  of  the 
liver  may  be  considered  of  advantage  in  making  clear  its 
pathologic  lesions.  This  organ  is  made  up  of  four  systems  of 
vessels — arteries,  portal  and  hepatic  veins,  and  bile  ducts. 
Each  or  all  of  these  may  be  subject  to  irritation  or  to  obstruc- 
tion as  the  result  of  interference  with  its  normal  physiologic 
function  or  to  disturbances  in  adjacent  organs.  Cardiac  and 
renal  disease  have  a  direct  influence  upon  the  liver.  Being 
an  important  organ  of  protein  metabolism,  it  is  possible  to 
determine  the  extent  of  the  disease  by  urea  production.  It  is 
the  cradle  and  the  grave  of  the  red  corpuscle,  and  is  directly 
concerned  with  sugar  digestion,  and  in  the  latter  capacity  is 


BILIOUSNESS.  875 

the  storehouse  for  carbohydrates.  It  produces  l)ilc,  an  essen- 
tial product  of  intestinal  indigestion. 

Because  of  its  special  anatomic  relation  between  the  re- 
turn circulation  from  the  liver  and  the  inferior  vena  cava,  the 
liver  is  subject  to  the  influence  of  interference  with  normal 
circulation  caused  by  cardiac  insufficiency.  Various  hepatic 
derangements  may,  therefore,  be  expected  in  cardiac  lesions. 

The  liver  receives  the  return  blood  from  the  stomach, 
spleen  and  intestines,  and  is  therefore  subject  to  irritation 
caused  by  various  products  resulting  from  deranged  function 
of  these  org-ans.  Certain  chemical  substances  have  a  special 
predilection  for  the  liver  when  taken  internally.  Disintegra- 
tion, degeneration,  and  irritation  may  result  from  the  influence 
of  such  preparations  as  phosphorus,  turpentine,  chloroform, 
ether,  mercury,  and  explosive  chemicals. 

Again,  the  liver  because  of  its  intimate  relation  with  the 
intestinal  tract,  may  harbor  the  infant  or  adult  forms  of  vari- 
ous parasites,  such  as  the  dog  tapeworm,  flukes,  ankylostoma, 
oxyuris,  and  others. 

Constant  irritation  leads  to  the  formation  of  excessive  con- 
nective tissue  at  the  expense  of  the  venous  supply,  causing 
a  damming  back  of  the  blood  into  the  intestinal  viscera,  pro- 
ducing a  chain  of  symptoms  described  later  under  cirrhosis  of 
the  liver. 

It  is  thus  seen  that  diseases  in  other  organs  may  produce 
changes  in  the  liver,  or  that  diseases  originating  in  the  liver 
itself  may  produce  s5^mptoms  in  other  organs.  In  other  words, 
when  the  hepatic  function  is  deranged,  the  S3miptoms  are  not 
only  referable  to  this  organ  but  to  the  whole  body. 

BILIOUSNESS. 

This  common  phraseology  is  applied  to  the  S3^mptom-com- 
plex  characterized  by  nausea,  usualty  with  vomiting,  coated 
tongue,  anorexia,  headache,  constipation  and  yellowish  or 
icteroid  complexion  of  the  skin,  and  a  feeling  of  Aveakness  or 
indisposition  for  mental  work.  It  occurs  after  indiscretion  in 
diet,  after  the  ingestion  of  certain  foods  known  to  disagree 
with  the  individual,  excessive  indulg'ence  in  alcoholic  bever- 


876  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

ag'es,  work  in  a  vitiated  atmosphere,  fatigue,  undue  excitement, 
and  inattention  to  personal  hygiene. 

TREATMENT. 

The  first  indication  in  the  way  of  treatment  is  to  obtain 
a  free  and  satisfactory  movement  of  the  bowels.  A  course  of 
calomel  taken  in  quantities  of  %  or  ^  g'rain  (0.01080  or 
0.01620  Gm.),  repeated  every  half-hour  until  1  grain  (0.065 
Gm.)  has  been  taken,  followed  one  hour  later  by  a  saline 
purge  of  Epsom  salts,  citrate  of  magnesia,  or  Glauber's  salts, 
may  clear  up  the  condition  without  further  medication.  In 
adult  males  of  middle  life  satisfactory  results  may  be  obtained 
by  the  administration  of  1  or  2  compound  cathartic  pills  at 
bedtime.  In  spite  of  their  griping  action,  they  seem  to 
move  the  most  stubborn  forms  of  constipation  and  relieve  the 
patient  of  all  toxic  products.  Nausea  often  may  be  relieved  by 
the  ingestion  of  plain  seltzer  water,  taken  ice  cold,  or  with  the 
addition  of  sodium  bicarbonate  or  sodium  phosphate. 

The  indiscriminate  use  of  coal  tar  products  and  of  patent 
preparations  for  the  relief  of  headache  during  attacks  of  bilious- 
ness is  severely  condemned  in  that  they  do  not  remove 
the  cause  of  the  predominant  symptoms.  There  are  many 
cases  on  record  of  poisoning  resulting  from  the  careless  use 
of  pills  for  liver  trouble. 

The  prevention  of  repeated  attacks  calls  for  especial  atten- 
tion to  personal  habits.  The  use  of  a  drastic  cathartic  at  least 
once  a  week  by  persons  who  are  constantly  constipated  is  of 
great  value.  Persons  who  lead  a  sedentary  life,  who  are  gen- 
erall}'-  employed  indoors,  and  who  obtain  very  little  exercise, 
should  make  it  a  point  toi  adopt  some  form  of  physical  calis- 
thenics in  the  early  morning  hours  before  breakfast,  or  at  least 
walk  to  or  from  work  if  possible.  In  various  industrial  pur- 
suits it  is  necessary  for  the  worker  to  assume  attitudes  and 
positions  which  cramp  the  abdominal  viscera,  thus  hindering 
normal  peristalsis.  In  various  establishments  employing  girls 
and  young  women,  accommodations  for  their  personal  needs 
are  inadequate  or  undesirable,  causing  them  to  become  in- 
different to  their  natural  inclinations  until  they  arrive  home 
in  the  late  evening  hours.  It  is  the  experience  of  many  physi- 
cians to  receive  complaints  from  patients  to  the  effect  that 


CATARRHAL  JAUNDICE.  877 

they  have  not  moved  their  bowels  for  three  or  four  days, 
and  sometimes  a  week,  resulting  in  chronic  constipation  and 
frequent  attacks  of  biliousness.  Persons  working"  under 
such  conditions  should  make  an  effort  to  have  a  daily 
movement  of  the  bowels  every  morning  or  every  evening.  If 
the  bowels  are  sluggish,  it  is  advisable  to  take  2  pills  consist- 
ing of  aloin,  belladonna,  strychnin,  and  cascara,  U.  S.  P.,  at 
bedtime,  and  repeat  it  until  the  bowels  become  regular.  Of 
late,  mineral  oil  has  become  quite  popular  in  facilitating  regu- 
lar passage  of  the  bowels,  and  may  be  administered  night  and 
morning,  a  half-ounce  (15  mils)  each  time.  Of  greatest  im- 
portance, however,  in  regulating  the  bowels  is  the  diet.  Liquid 
foods  should  be  taken  in  plenty.  Vegetables  and  stewed 
fruits  assist  in  causing  semi-solid  movements.  Persons  sub- 
ject to  biliousness  should  avoid  shell-fish,  fatty  foods,  rich 
pastries,  and  smoked  meats.  Persons  of  neurotic  tendency  or 
subject  to  so-called  nervous  biliousness  should  be  placed  under 
the  influence  of  bromids. 

JAUNDICE. 

Jaundice  is  a  symptom-complex  characterized  by  the 
staining  of  the  skin,  conjunctivae,  and  the  secretions  of  the 
body  (saliva,  urine,  and  sweat)  with  bile  pigments.  It  is 
caused  by  obstruction  of  the  normal  flow  of  bile  in  the  liver, 
in  the  common  bile  duct  or  in  the  duodenum.  Inflammation 
of  the  common  bile  duct  and  duodenum  is  probably  the  most 
frequent  cause.  Among"  the  obstructive  agencies  are  gall- 
stones, parasites,  tumors,  displacements  of  viscera,  enlarged 
glands,  floating  kidney,  and  pregnant  uterus.  The  stagnant 
bile  is  absorbed  by  the  general  blood-stream,  resulting  in  stain- 
ing of  the  tissues  of  the  body,  both  internally  and  externally, 
while  the  chemical  properties  of  the  bile  have  a  depressing 
influence  upon  the  nervous  system. 

CATARRHAL  JAUNDICE. 

This  condition  arises  from  a  catarrhal  condition  of  the  bile- 
ducts  and  duodenum  in  the  immediate  vicinity  of  the  ampulla 
of  Vater,  producing  general  discoloration  of  the  surface  of 
the  body,  and  attended  with  various  nervous  symptoms. 


878  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

The  liver  is  slightly  enlarged,  lighter  in  color  than  normal, 
and  bile-stained.  On  section,  the  bile-ducts  are  patulous  and 
distended  with  bile.  The  surface  of  the  cut  section  is  stained, 
the  common  duct  is  swollen,  its  mucous  membrane  thickened, 
and  its  lumen  filled  with  viscid  bile,  whch  can  be  expressed 
by  pressure.  Section  of  the  duodenum  will  also  reveal  a 
hyperemic  condition  of  the  mucosa.  j\Iicroscopically,  the  liver 
cells  are  dotted  with  bile  pigment,  imparting  a  dark  greenish 
color.  In  marked  cases  the  pigment  collects  in  irregular 
masses  in  the  bile  capillaries.  The  pigmentation  is  most 
marked  in  the  central  zone  of  the  lobules. 

]\Iarked  constipation  is  a  frequent  predisposing  cause. 
Overeating,  improperly  cooked  and  poorly  masticated  food, 
excessive  use  of  alcohol,  coffee  and  tea,  mental  and  phj'-sical 
fatigue,  exposure  to  wet  and  cold,  certain  infectious  diseases 
(pneumonia,  typhoid  fever,  malaria),  and  cardiorenal  disease 
with  failure  of  compensation,  are  among  the  many  exciting 
factors.  The  inflammation  begins  in  the  duodenum  and 
travels  upward  through  the  common  duct. 

Jaundice  is  the  most  frequent  symptom,  aflfecting  the  en- 
tire skin  surface  and  conjunctiva,  the  latter  presenting  a 
lemon-yellow  color.  The  urine  and  sweat  are  often  discolored, 
perhaps  so  decidedly  as  to  stain  the  bed-linen.  The  urine 
varies  from  a  greenish  yellow  to  dark  brown.  When  thor- 
oughfy  shaken  in  a  bottle,  a  3^ellow  foam  appears  on  the  sur- 
face, while  bile  often  may  be  detected  in  the  urine  before  it 
affects  the  skin  and  conjunctivse.  In  cases  of  moderate  dura- 
tion, albumin  and  hyaline  casts,  the  latter  often  bile-stained, 
mav  be  found.  The  stools  lack  their  normal  color,  being  pale 
drab  or  slate.  The  bowels  are  costive,  but  later  may  be  very 
loose.  Occasionally  the  tears  and  saliva  are  stained.  The 
temperature  may  be  normal  or  slightly  elevated  (100°  F.  to 
101°  F.— 37.7°  C.  to  38.3°  C),  while  the  pulse  is  slow  but  full 
(as  low  as  20  to  30).  There  is  tenderness  over  the  hepatic 
area,  and  paroxysms  of  pain,  which  may  be  severe  or  slight, 
and  accompanied  by  nausea,  sometimes  vomiting,  headache, 
and  prostration.  Itching  is  a  common  symptom.  Urticarial 
eruptions  may  appear  upon  the  body.  Free  sweating  is  fre- 
quently complained  of;  it  may  be  either  general  or  localized 
to  the  abdomen  and  the  palms  of  the  hands.    In  various  cases 


CATARRHAL  JAUNDICE.  879 

of  jaundice,  hemorrhag'e  may  occur  beneath  the  skin  and 
mucous  membranes.  The  toxic  effect  of  bile  absorption 
causes  a  feeling  of  mental  and  physical  depression,  headache, 
and  fatigue.  *  When  existing  with  carcinoma,  acute  yellow 
atrophy  of  the  liver,  and  fatty  degeneration,  the  nervous 
symptoms  are  intensified,  approaching  delirium,  and  often- 
times causing  convulsions  or  coma,  which  may  terminate 
fatally.  The  vision  may  become  affected,  the  patient  com- 
plaining of  colored  objects  before  the  sight. 

On  examination  the  liver  is  found  to  be  enlarged,  the  de- 
gree of  the  hepatomegah'-  depending-  upon  the  duration  and 
severity  of  the  bile  obstruction.  The  border  of  the  liver  may 
reach  several  inches  below  the  costal  edge.  Palpation  or  per- 
cussion over  the  liver  and  g'all-bladder  area  elicit  tenderness 
and  cause  pain,  commonly  referred  to  the  back.  The  disease 
may  last  for  from  two  to  eight  weeks.  Cases  prolonged  be- 
yond this  period  may  be  rightfully  considered  as  other  than 
simple  catarrh.  The  prognosis  is  favorable.  When,  however, 
there  is  a  continued  rise  of  temperature,  or  when  there  are 
subcutaneous  and  submucous  hemorrhages,  the  prognosis  is 
less  favorable. 

TREATMENT. 

If  the  pain  is  severe,  it  is  relieved  by  hypodermic  injec- 
tion of  morphin,  ^4  grain  (0.01620  Gm.),  repeated  in  a  half- 
hour  if  the  suffering  demands  it.  The  patient  should  be  kept 
in  bed  and  hot  compresses  placed  over  the  hepatic  area  for 
twenty  minutes  in  ever}^  hour.  The  bowels  may  be  moved  by 
the  administration  of  compound  jalap  powder,  in  a  dose  of 
from  30  grains  to  1  dram  (1.95  to  3.9  Gm.)  at  bedtime.  In 
the  morning  effervescent  solution  of  phosphate  of  soda,  1 
dram  (3.9  Gm.)  to  half  a  glass  of  hot  water  given  a  half-hour 
before  breakfast,  is  quite  acceptable.  If  the  bowel  movements 
are  not  satisfactory,  a  dose  of  citrate  of  magnesia  should  be 
given.  If  the  attack  is  a  mild  one  and  there  is  no  fever  and 
the  pain  has  subsided,  the  patient  may  be  allowed  out  of  bed 
and  the  treatment  continued.  Chronic  constipation  calls  for 
repeated  enemata,  using  simple  salt  solution,  soap  suds,  or 
emulsion  of  asafetida.  A  tablespoonful  of  milk  of  magnesia 
(15  mils)  should  be  given  at  bedtime  to  soften  the  stool. 

The  diet  plays  a  very  important  part  in  the  treatment  of 


880  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

catarrhal  jaundice.  Milk  alternated  by  buttermilk  or  skim 
milk  should  constitute  the  main  diet  for  the  first  two  days. 
Ice  is  quite  acceptable  in  allaying  nausea.  Although  acids  in 
general  are  contraindicated,  the  juice  of  sweet  oranges  with 
shaved  ice  makes  a  palatable  drink,  allays  the  thirst,  clears 
the  stomach  of  mucus  and  bile,  and  sweetens  the  taste.  A 
draught  of  plain  ice-cold  seltzer  water  is  also  acceptable  in 
that  it  assists  in  dissolving  the  mucus  in  the  stomach,  en- 
courages peristalsis  and  dilutes  the  toxic  products.  All  fats 
and  rich  pastries  are  to  be  prohibited.  As  the  jaundice  dis- 
appears there  may  be  added  to  the  diet  strained  beef  broth, 
beef  tea,  milk  toast,  gelatin,  custard,  and  tapioca  pudding; 
later,  chicken,  squabs,  and  boiled  beef  are  permitted.  Stewed 
prunes  may  be  added,  as  well  as  baked  apples  and  cream.  In 
spite  of  the  fact  that  the  liver  is  specially  concerned  in  sugar 
metabolism,  a  small  amount  of  carbohydrates  in  the  diet  is 
permissible.  A  full  diet  is  given  only  after  the  jaundice  has 
completely  disappeared. 

Among  the  drugs  which  are  valuable  are  sodium  salicylate 
and  sodium  succinate,  each  3  grains  (0.195  Gm.)  in  capsule 
three  times  a  day;  sodium  bicarbonate,  10  grains  (0.65  Gm.), 
potassium  citrate,  10  grains  (0.65  Gm.),  or  dilute  hydrochlorate 
acid,  10  minims  (0.65  mils),  given  in  tincture  of  gentian,  car- 
damom or  essence  of  pepsin,  as  a  routine  measure.  Efferves- 
cent phosphate  of  soda  may  be  taken  daily,  1  dram  (3.75  mils) 
to  a  half-glass  of  hot  water  a  half-hour  before  breakfast.  A 
full  tub  bath  should  be  taken  daily  in  order  to  aid  in  eliminat- 
ing the  toxic  products  through  the  skin  and  to  stimulate  the 
circulation  with  a  view  of  causing  a  return  of  normal  func- 
tion of  the  liver.  Itching  may  be  controlled  by  the  application 
of  a  2  per  cent,  solution  of  menthol  in  alcohol.  Bromids  are 
advocated  in  abating  the  nervous  symptoms.  Should  the 
jaundice  recur  or  be  prolonged,  colonic  irrigation  of  the  bowel 
is  advocated,  using  from  2  to  3  liters  (2  to  3  qts.)  of  salt  solu- 
tion at  each  seance.  This  dilutes  the  toxic  products,  stimu- 
lates the  portal  circulation,  and  favors  normal  peristalsis.  If 
after  the  acute  symptoms  have  subsided  the  jaundice  still 
lingers  on,  a  course  of  calomel  given  for  two  or  three  days,  in 
doses  of  i/4o  grain  (0.00648  Gm.),  followed  by  Epsom  salts  or 
citrate  of  magnesia,  may  assist  in  favoring  the  abatement  of 


ACUTE  INFECTIOUS  JAUNDICE.  881 

symptoms.  Jaundice  caused  by  pressure  of  neoplasms,  g'all- 
stones,  or  similar  causes  calls  for  operative  interference  and 
drainage  of  the  gall-bladder. 

ACUTE  INFECTIOUS  JAUNDICE. 

Surgeon-General  Blue,  U.  S.  Public  Health  Service,  has 
granted  the  authors  permission  to  reproduce  under  Diseases  of 
the  Liver  the  subject  matter  of  acute  infectious  jaundice,  as 
published  by  the  U.  S.  Public  Health  Service  in  its  Report  of 
May  10,  1918,  by  M.  H.  Neill,  Passed  Assistant  Surgeon. 
Since  the  material  furnished  in  this  article  contains  the  latest 
information  on  the  subject  of  acute  infectious  jaundice,  com- 
mon among  the  troops  in  France,  and  occurring  in  scattered 
areas  throughout  the  United  States,  it  is  deemed  best  to  re- 
peat this  article  as  originally  published : — 

"Acute  infectious  jaundice  is  an  acute  infectious  disease 
characterized  by  malaise,  prostration  and  gastro-intestinal 
symptoms  at  onset,  by  fever  of  varying  degree  and  by  jaun- 
dice of  varying  intensity  and  duration.  In  severe  cases  bleed- 
ing from  mucous  surfaces  and  albuminuria  are  common.  In 
moderately  severe  cases  the  rather  high  fever,  marked  pros- 
tration and  absence  of  local  signs  tend  to  exclude  local  dis- 
ease of  the  biliary  tract,  and  present  the  clinical  picture  of  an 
acute  infection.  Light  cases  of  this  affection,  however,  seem 
to  be  clinically  indistinguishable  from  ordinary  catarrhal 
jaundice,  and  therefore  are  seldom  diagnosed  correctly  in  the 
absence  of  an  outbreak  of  the  disease,  which  naturally  directs 
attention  to  the  probably  infectious  character  of  the  malady. 

Prevalence  of  the  Disease  Among  Troops  in  Europe.  It  is 
well  known  that  outbreaks  of  jaundice  have  occurred  at  different 
times  among  the  French,  Br'itish,  Italian,  Gemian  and  Russian 
troops.  The  geographical  range  of  prevalence  has  been  from 
Belgium  to  Gallipoli.  In  most  of  the  outbreaks  the  mortality 
has  been  low,  but  in  some  of  the  commands  the  attack  rate  has 
been  high. 

At  this  time  the  weight  of  evidence  indicates  that  the 
'disease  in  the  great  majority  of  instances,  if  not  in  all,  has 
been  due  to  the  Spirochccta  icterohcrmorrhaguu  of  Inada 
(1916)   and  his  co-workers.     This  organism  was  first  demon- 

56 


882  DISEASES   OF   THE   DIGESTIVE    SYSTEM. 

strated  as  the  cause  of  a  severe  form  of  the  disease  prevalent 
in  Japan. 

Prevalence  of  the  Spirochccta  Icterohcsmorrhagice  Among 
Wild  Rats  in  the  United  States.  Noguchi  (1917)  found  that  rats 
captured  about  New  York  City  were  infested  with  a  spirochseta 
identical  in  appearance  with  that  causing  acute  spirochaetal  jaun- 
dice in  man.  This  worker,  by  means  of  cross  immunity  tests, 
presented  further  evidence  that  the  parasites  causing  the  human 
disease  in  Europe  and  Japan  and  those  found  in  New  York  rats 
were  the  same.  Jobling  (1917)  found  that  of  more  than  a 
hundred  rats  captured  in  Nashville,  Tenn.,  at  least  10  per  cent, 
carried  similar  spirochsetes  in  their  kidneys.  The  writer  has 
found  a  similar  prevalence  of  the  Spirochceta  icterohc€morrhagi<E 
in  wild  rats  captured  in  Washington,  D.  C.  As  far  as  can  be 
made  out  the  organisms  found  by  different  workers  in  the 
United  States  correspond  very  closely  in  appearance  and  patho- 
genicity for  guinea  pigs  with  those  infecting  human  beings  in 
the  trenches  in  Europe  and  in' the  mines  of  Japan.  The  evidence 
then  seems  to  indicate  pretty  conclusively  that  the  SpirocJurta 
icterohcEmorrhagia;,  the  cause  of  acute  spirochaetal  jaundice  in 
man,  is  rather  widely  disseminated  among  wild  rats  living  under 
such  different  conditions  of  environment  as  obtain  in  New  York, 
Washington,  and  Nashville.  Reports  of  the  degree  of  preva- 
lence of  these  parasites  in  the  rats  throughout  the  country  are 
awaited  with  considerable  interest. 

Reported  Occurrence  of  Epidemic  Jaundice  in  the  United 
States.  A  search  of  the  literature  reveals  a  number  of  outbreaks 
of  jaundice  occurring  from  time  to  time  in  this  countr}^  Even 
though  few  and  far  between,  on  account  of  the  prevalence  of 
the  causative  agent  in  wild  rats,  and  the  fact  that  outbreaks  of 
jaundice  tend  to  occur  among  troops,  these  reports  deserve  at 
least  a  passing  consideration. 

An  account  of  an  outbreak  of  jaundice  among  troops  in  the 
War  of  1812  has  come  down  to  us.  Acute  infectious  jaundice 
has  been  stated  to  have  been  highly  prevalent  during  the  Civil 
War,  and  various  numerical  estimates  of  its  prevalence  appear  in 
the  literature.  The  following  quotation  is  taken  from  the  ]\Iedi- 
cal  and  Surgical  History  of  the  \\"ar  of  the  Rebellion  prepared 
under  direction  of  the  Surgeon-General,  United  States  Army: 
'Jaundice  occurred  frequently  in  the  progress  of  the  malarial  or 


ACUTE  INFECTIOUS  JAUNDICE.  883 

other  fevers  as  the  result  of  morbid  changes  affecting  the  hver 
or  blood.  The  yellow  coloration  in  these  cases  was  mostly  an 
incident  or  symptom  of  the  well-defined  primary  disease.  There 
were,  however,  a  large  number  of  hepatic  or  haematic  disorders 
in  which  the  alteration  of  color  represented  so  prominent  a  symp- 
tom that  the  disease  was  recorded  under  the  heading  of  jaundice. 
Not  less  than  71,691  cases  of  this  kind  were  reported  among 
white  troops  (Union  Anny).  Generally  the  cases  were  sporadic, 
but  sometimes  a  series  occurred  in  a  command  constituting  a 
local  epidemic' 

While  in  the  report  just  quoted  the  association  of  jaundice 
with  disease  of  the  liver  and  malaria  is  recognized,  the  records 
contain  several  accounts  of  clear-cut  outbreaks  of  jaundice  and 
fever  corresponding  pretty  closely  to  the  descriptions  of  the 
trench  jaundice  observed  in  the  present  war.  It  seems,  then, 
that,  while  outbreaks  of  acute  infectious  jaundice,  very  likely 
due  to  spirochsetes,  occurred  during  the  Civil  War,  a  numerical 
estimate  of  the  prevalence  of  the  disease  should  not  be  attempted. 

A  search  of  the  literature  reveals  a  number  of  reports  of  out- 
breaks of  jaundice  among  the  civil  population  in  the  United 
States.  In  the  majority  of  these  reports  no  special  prevalence  of 
other  febrile  diseases  is  mentioned  in  connection  with  the  cases 
reported.  In  many  of  the  cases  the  observers  were  impressed 
with  the  fact  that  they  were  dealing  with  a  condition  they  had 
never  seen  before,  basing  their  diagnosis  on  the  description  of  the 
disease  as  it  occurs  in  Europe. 

In  all  the  American  reports  most  of  the  patients  experienced 
nausea  or  vomiting,  some  abdominal  distress  or  pain,  headache, 
and  fever  of  varying  degree,  followed  in  a  few  days  by  jaundice 
of  varying  intensity.  It  fact  from  many  of  the  descriptions  there 
is  little  to  suggest  a  specific  infectious  disease,  aside  from  the 
fact  that  a  number  of  cases  as  described  above  would  appear  at 
about  the  same  time  in  a  community  which  was  both  previously 
and  subsequently  free  from  the  disease.  Several  reports  indi- 
cate a  high  mortality  among  pregnant  women.  In  some  out- 
breaks children  seem  to  have  been  chiefly  attacked,  in  others 
adults,  and  in  still  others  adults  and  children  were  equally 
affected.  In  some  outbreaks  males  were  principally  affected, 
while  in  others  both  sexes  were  affected  about  equally.  In  sev- 
eral outbreaks  the  symptomatology  in  the  fatal  cases  was  strik- 


884  DISEASES    OF   THE    DIGESTIVE    SYSTEM. 

ingly  similar,  suggestive  of  rapid  necrosis  of  the  liver  cells  as 
occurs  in  acute  yellow  atrophy  of  the  liver.  There  is  no  infor- 
mation as  to  the  occupation  of  those  ill  with  the  disease,  nor  is  it 
possible  to  gain  any  comprehensive  idea  of  the  sanitary  situation 
as  regards  water  and  food  supply,  sewage  disposal,  and  the  like, 
under  which  the  disease  has  occurred  in  the  United  States.  No 
adequate  study  of  the  pathology  of  the  disease  in  man  in  this 
country  has  come  to  the  writer's  attention.  Barker  and  Sladen 
found  that  the  blood  serum  of  their  cases  agglutinated  a  strain  of 
B.  paratyphostis. 

There  is  some  evidence  to  suggest  that  direct  contact  may 
have  occasionally  played  a  part  in  transmitting  the  disease,  as  in 
Hanover,  N.  H.  (Gile,  1908),  where  a  number  of  college  stu- 
dents were  engaged  in  surveying  roads  in  the  vicinity,  camping 
out  at  night.  From  time  to  time  one  would  become  ill  with 
jaundice  and  fever  and  return  to  college.  Then  cases  began  to 
appear  in  the  college  itself  where  the  disease  had  formerly  been 
unknown.  Again,  at  Ann  Arbor,  Mich  (Cummings,  1915),  12 
of  the  19  cases  had  been  in  contact  with  a  sick  college  mate  pre- 
vious to  contracting  the  disease.  In  this  outbreak  the  food  sup- 
ply was  apparently  not  a  factor,  as  nearly  all  those  attacked  ate 
at  separate  boarding  houses. 

From  the  table  (p.  885)  it  is  evident  that,  while  in  certain 
of  the  outbreaks  a  fairly  large  proportion  of  the  community 
has  been  attacked,  the  case-fatality  rate  has  always  been  lov.^ 
As  regards  seasonal  prevalence,  it  w^ould  seem  that  the  few^est 
cases  occurred  in  the  warmer  months  of  the  year.  Detailed 
analysis  of  the  reports  shows  very  few  cases  occurring  in  the 
summer  as  compared  with  the  fall  and  winter.  This  is  in 
accordance  with  a  part  of  the  observation  of  Japanese  and 
European  workers,  that  the  disease  does  not  occur  in  the 
hottest  or  coldest  weather. 

Before  closing  the  discussion  as  to  the  prevalence  of  epi- 
demics of  jaundice  in  the  United  States  it  seems  fair,  in  the  ab- 
sence of  more  definite  knowledge,  to  ask  whether  such  a  disease 
as  a  separate  entity  has  existed  or  whether  all  the  outbreaks 
were  not  manifestations  of  some  other  disease  such  as  typhoid 
fever  or  malaria.  With  regard  to  malaria  it  may  be  said  that, 
while  estivo-autumnal  malaria  undoubtedly  caused  outbreaks  of 
jaundice  in  the  Civil  War,  it  is  contrary  to  our  present  knowl- 
edge of  the  distribution  of  this  disease  to  ascribe  such  outbreaks 


ACUTE  INFECTIOUS  JAUNDICE. 


88: 


as  occurred  in  Maine,  New  Hampshire,  Minnesota,  and  Wiscon- 
sin to  this  cause.  To  infer  that  these  cases  were  due  to  some 
vagary  of  B.  typhosus  would  contradict  a  great  mass  of  cHnical 
experience,  which  shows  that  jaundice  is  a  very  rare  symptom  of 
typhoid  fever.  The  same  may  be  said  with  regard  to  paratyphoid 
infection.  In  general  the  seasonal  prevalence  of  acute  infectious 
jaundice  seems  to  be  at  its  lowest  just  when  so-called  filth-borne 
diseases  are  most  prevalent. 

Whatever  may  be  the  weight  attached  to  such  facts  as  have 
been  stated  above  they  indicate  that  epidemics  of  jaundice  closely 
simulating  those  now  known  to  be  caused  by  the  Spirocliccta 
ictcrohccmorrkagicc  have  occasionally  appeared  in  this  country, 
and  that  they  were  possibly  due  to  this  parasite.  This  latter 
statement  is  strengthened  by  the  finding  by  A.  M.  Stimson  (per- 
sonal communication)  of  spirochsetes  in  sections  of  the  kidney  of 
a  man  who  died  in  New  Orleans  of  a  disease  characterized  by 
jaundice  and  fever.  These  sections  prepared  by  Levaditi's 
method  show  spirochsetes  morphologically  similar  to  the  causa- 
tive agent  of  acute  spirochgetal  jaundice. 

The  Problem   of   the  Rat  as  a   Carrier  of   the   Spirochccta 


Place. 


Rocky  Mount,  N.  C 

Halifax  Court  House,  Va. 


Savannah,  Ga 

Birmingham,  Ala. 
Plainfield,  Mich.  .. 
Geneva,   N.   Y.    ... 


Troy,  Me.  .. 
Sparta,  Wis. 


Calumet,  Mich.,  and  vicin- 
ity   

Hanover,  N.  H 

Stirling,  Kans 


Montevallo,   Ala. 
Talladega,  Ala.   . 


Baltimore,  Md. 


Andover,  Me.  .. 
Austin,  Minn.  . 
New  York  City 


Hetland,  S.  Dak. 
Ann  Arbor,  Mich. 


Approxi- 
mate 

popula- 
tion. 


30,000 

3,000 

100 

7,000 


3,000 


30,000 
4,000 
2,200 


5,500 
558,500 


750 

6,960 

4,800,000 


223 
15,000 


Year. 


1849-50 
1857-58 


1880 
1881-82 
1886-87 


1887 
1898 


1897-98 
1899 
1905 

1906 
1907 

1908 


1908-09 

1910 
1912-13 


1913 
1915 


Nov.,   Dec, 
Jan 

Fall  and  win- 
ter     

Jan.,  Feb.  ... 
Sept. -Jan.  ... 
Oec,  Jan.  .. 
Spring    

do    

Aug.,   Sept., 
Oct.    

June)- Jan.  . . . 
Not  stated  . . 
Sept.,    Oct., 

Nov 

Nov.,  Dec.  .. 
Summer      and 

fall     

Nov.,   Dec.   .. 


Oct. -Feb. 
Sept.-Dee. 
Oct. -Jan. 


June-Sept. 
Spring    ... 


Cases. 


About    40.. 
Not  stated 


SO     

"Many" 

22     

200     


Not  stated 
"Few"    ... 


675     

About    25 


30    

Not  stated 


Deaths. 


About  200  .. 
6    cases,     of 

700   inmates 

of   jail    

135     

About  200  .. 
25  studied  at 

author's 

clinic     

Not  stated  . 
25    


Not  stated 

Apparently 
none. 
None 
"Few" 
None 
None  men- 
tioned, 
do 

"Few" 

None 
do 


None 


None 
do 
do 


Not  stated 
None 


886  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

IcterohcrmorrJiagi^r.  The  following  quotation  from  Noguchi  is 
well  adapted  as  a  starting  point  in  this  discussion:  'The  finding 
of  the  causative  organism  of  infectious  jaundice  among  wild  rats 
in  America  and  the  identification  of  this  strain  with  those  found 
in  Asia  and  Europe  seem  to  be  particularly  important  in  revealing 
a  latent  danger  to  which  we  have  been  constantly  exposed,  but 
from  which  we  escape  as  long  as  sanitarj^  conditions  are  not  dis- 
turbed by  untoward  events.' 

Long  before  the  present  war  acute  infectious  jaundice  was 
recognized  to  occur  especially  among  troops,  among  sewer 
workers,  agricultural  laborers  working  in  wet  soil,  and  in  mine 
workers.  People  who  handle  food  as  butlers  and  cooks,  in 
Japan  at  least,  are  also  said  to  be  attacked  with  especial  fre- 
quency. With  the  universal  adoption  of  trench  zvarfare  in  the 
present  conflict  acute  infectious  jaundice  took  a  more  or  less 
prominent  place  in  the  category  of  trench  diseases.  Stokes 
(ipiy)  observed  a  definite  increase  in  the  number  of  cases  among 
troops  during  zvet  spells  of  weather^  followed  by  a  diminution  in 
cases  zi'hen  the  iveather  became  dry.  It  was  also  noted  that  a 
regiment  which  had  a  number  of  cases  in  the  line — i.e.,  wet 
trenches — was  not  infected  while  in  rest  billets,  but  again  pro- 
duced cases  when  it  returned  to  the  trenches.  In  Japan,  Inada 
(1916)  and  his  co-workers  found  that  cases  of  acute  infectious 
jaundice  occurred  in  the  wet  shafts  of  the  mine,  but  not  in  the 
dry  shafts  nor  on  the  surface.  Some  evidence  has  been  presented 
to  show  that  the  hot  and  cold  months  of  the  year  are  unfavor- 
able to  the  spread  of  the  disease.  Several  laboratory  workers 
have  been  directly  infected  by  the  blood  of  guinea  pigs  suffering 
from  the  disease,  at  least  once  with  fatal  outcome. 

The  credit  of  first  finding  the  Spirochccta  icterohcemorrhagice 
in  rodents  belongs  to  the  Japanese  investigators,  who  first  demon- 
strated these  parasites  in  the  kidneys  of  field  mice.  Further  in- 
vestigations in  the  coal-mining  regions  of  Japan  showed  that  40 
per  cent,  of  the  wild  rats  harbored  organisms  resembling  these 
parasites.  ]\Iany  cases  of  infectious  jaundice  in  human  beings, 
due  to  spirochsetes,  occur  in  this  region.  With  regard  to  the 
spirochsetes  found  in  the  rats,  it  was  observed  that  they  live  in 
the  kidney  without  injury  to  the  animal,  and  are  excreted  in  the 
urine.  By  means  of  tests  with  immune  sera,  evidence  was  ob- 
tained which  indicated  that  the  spirochaetes  which  came  from  the 


ACUTE  INFECTIOUS  JAUNDICE.  887 

rats  were  quite  similar  to,  if  not  identical  with,  those  derived 
from  human  sources.  The  various  strains  of  these  spirocha;tes 
all  produced  the  same  striking  pathological  picture  in  experimen- 
tally infected  guinea  pigs.  Guinea  pigs  were  infected  by  allow- 
ing rats  to  bite  them,  and  it  was  demonstrated  also  that  the 
organisms  would  pass  through  the  unbroken  skin  of  these  animals. 

English  and  French  workers  soon  demonstrated  the  presence 
of  the  Spirochccta  ictcrohcumorrhagicc  in  rats  taken  from  the 
trenches  in  which  the  disease  had  appeared  among  troops.  Thus 
Stokes  (1917)  found  6  out  of  15  rats  to  be  infected.  On  the 
other  hand,  Courmont  and  Durand  (1917)  examined  50  rats 
taken  in  a  region  where  acute  infectious  jaundice  was  unknown. 
The  rats  appeared  perfectly  healthy,  but  four  of  them  were 
proved  by  guinea-pig  inoculation  to  harbor  the  Spirochata  ictero- 
hcemorrhagicc.  These  figures  approximate  the  rate  of  incidence 
later  obtained  for  wild  rats  in  the  United  States.  Rat  infestation 
has  been  demonstrated  in  other  portions  of  France. 

With  regard  to  the  relation  between  rat  infestation  and 
human  infection  with  Spirochccta  icterohcemorrhagm,  two  possi- 
bilities present  themselves.  First,  it  is  possible  that  no  transfer 
from  rats  to  man  takes  place,  or  only  exceptionally,  as  in  case  of 
a  bite.  It  may  be  that  some  cause  is  at  work  in  the  trenches  and 
mines  which  tends  to  infect  man  and  rats  with  the  Spirochccta 
icterohcomorrhagice  entirely  independently  of  each  other.  On  the 
other  hand,  it  seems  more  probable  that  the  spirochsetes  may  be 
interchanged  indiscriminately  among  men  and  rats  living  in  such 
environments  as  obtain  in  the  trenches,  by  means  of  their  urine. 
There  is  evidence  to  show  that  infection  can  take  place  either 
through  the  skin  or  by  the  mouth.  There  is  no  adequate  evi- 
dence that  any  insect  plays  a  part  in  the  transmission  of  the  dis- 
ease in  nature,  although  the  experimental  evidence  in  this  regard 
is  by  no  means  complete.  The  epidemiology  of  the  disease  seems 
to  point  rather  definitely  to  a  moist  soil,  at  an  equable  tempera- 
ture, as  a  means  of  keeping  alive  the  virus. 

While  the  problem  of  the  rat  in  relation  to  acute  infectious 
jaundice  has  not  been  completely  worked  out,  the  following 
statement  of  the  mode  of  transfer  forms  a  reasonable  hypothesis. 
About  10  per  cent,  of  all  wild  rats  wherever  located  probably 
carry  the  Spirochccta  icterohccmorrh agicc  in  their  kidneys  and  ex- 
crete them  in  their  urine.    If  this  organism  finds  a  favorable  en- 


DISEASES    OF   THE   DIGESTIVE   SYSTEM. 

vironment  in  the  soil,  a  sufficient  number  may  live  long  enough 
to  infect  a  human  being  who  gets  them  in  the  mouth  or  on  the 
skin.  Under  these  conditions  a  larger  number  of  rats  also  take 
up  the  spirochsetes. 

jMuch  more  work  needs  to  be  done  to  place  the  whole  matter 
on  a  sound  scientific  basis,  and  to  do  this  it  is  essential  to  (1) 
recognize  cases  of  the  disease  in  man,  (2)  determine  the  general 
prevalence  of  the  Spirochata  kterohccmorrhagicB  in  wild  rats, 
living  in  various  environments. 

Detection  of  the  Spirocliccta  Icteroiiccmorrhagiiu  by  Laboratory 
Methods: 

(a)  In  man. 

The  following  methods  have  been  successfully  employed  in 
detecting  infection  with  the  Spirochccta  icterohcumorrJiagicc  in 
human  beings : 

1.  Examination  of  blood  films.  These  have  been  stained  for 
spirochsetes  by  one  of  the  Romanowski  stains  or  one  of  the 
silver  impregnation  methods. 

2.  Examination  of  the  blood  by  dark  field  illumination. 

3.  Injection  of  the  blood  into  the  peritoneal  cavity  of  a 
guinea  pig. 

In  these  three  methods,  the  earlier  in  the  course  of  the  dis- 
ease the  blood  is  obtained  the  better  the  chances  of  success.  In 
the  first  two  methods  search  must  be  made  with  the  microscope 
for  the  spirochsetes ;  and'  as  they  are  not  very  numerous  in  the 
blood  of  human  cases,  and  somewhat  difficult  to  stain,  these 
methods  are  not  highly  satisfactory.  On  the  other  hand,  in  early 
cases  guinea-pig  inoculation  with  blood  is  a  valuable  procedure, 
and  should  always  be  done,  unless  the  patient  is  first  seen  late  in 
the  disease.  If  the  Spirochccta  icteroJicrniorrhagicc  are  present  in 
the  inoculated  blood  the  guinea  pig  will  usually  sicken  and  die 
in  about  ten  days.  Post-mortem  examination  will  show  a  well 
marked  combination  of  jaundice  and  hemorrhage  such  as,  so  far 
as  known,  is  not  produced  by  any  other  infection. 

In  a  light-skinned  guinea  pig  a  distinct  yellowish  tinge,  espe- 
cially noticeable  in  the  ears  and  about  the  genitals,  is  usually 
observed.  On  dividing  the  skin  of  the  abdomen  in  a  case  of  this 
disease,  the  operator  is  at  once  struck  with  the  widespread 
hemorrhages  which  lie  beneath  the  skin  and  between  the  con- 
nective tissue  planes.     They  range  from  minute  petechiae  up  to 


ACUTE  INFECTIOUS  JAUNDICE.  889 

massive  effusions  of  blood  perhaps  a  centimeter  in  diameter. 
The  hemorrhages  are  especially  well  marked  about  the  axillary 
and  inguinal  lymph-nodes,  and  as  the  skin  is  reflected  hemor- 
rhagic areas  will  be  seen  between  the  fascia  covering  the  skeletal 
muscles.  The  skin  is  usually  quite  yellow  and  the  abdominal 
muscles  frequently  show  a  yellowish  tinge.  On  opening  the  body 
cavity  the  liver  appears  distinctly  enlarged  and  of  a  brownish- 
yellow  color.  The  spleen  is  not  enlarged.  The  intestines  are 
stained  yellow,  and  hemorrhages  into  the  intestinal  walls  are  of 
frequent  occurrence.  Post-peritoneal  hemorrhages  are  frequent 
and  abundant,  especially  about  the  kidney  and  adrenal.  This 
organ  is  frequently  the  seat  of  marked  effusions  of  blood.  In 
the  thorax  the  lungs  especially  attract  attention,  being  the  seat  of 
the  most  characteristic  gross  change  observed  in  the  guinea  pig. 
These  consist  of  numerous  sharply  defined  hemorrhagic  foci. 
The  description,  by  the  Japanese,  of  the  lungs  as  resembling  the 
mottled  wings  of  a  butterfly  is  a  very  apt  one.  Histologically  the 
liver  and  kidneys  show  the  most  characteristic  changes.  The 
liver  shows  an  exudation  of  polymorphonuclear  leucocytes  about 
the  bile-ducts,  and  widespread  degenerative  changes  of  the 
parenchyma.  Many  of  the  cells  contain  an  abnormal  amount 
of  pigment,  while  others  show  pronounced  vacuolization  and 
dispersion.  The  kidneys  show  an  acute  exudative  nephritis 
with  hemorrhages  throughout  the  cortex. 

The  tissues  of  the  guinea  pig  contain  many  spirochaetes,  which 
may  be  best  demonstrated  by  staining  portions'  of  the  liver  by  the 
older  method  of  Levaditi,  making  sections  and  examining  by  the 
microscope.  Dark  field  examination  of  the  liver  pulp  will  also 
usually  reveal  them. 

4.  Microscopic  examination  of  the  urine  for  spirochaetes. 

The  urine  is  centrifugalized  and  the  sediment  examined  by 
the  dark  field  method,  or  films  are  made  and  stained  by  India  ink, 
Romanowsky  stain  or  a  silver  impregnation  method.  It  will  be 
recalled  that  the  urine  contains  spirochaetes  in  a  variety  of  con- 
ditions, and  one  must  be  entirely  familiar  with  the  morphology 
of  the  Spirochccta  icterohccmorrhagia:  to  hazard  a  diagnosis  by  a 
microscopic  examination  of  the  urine. 

The  microscopic  examination  of  the  urine  has  a  special  field 
in  expert  hands  to  determine  whether  a  convalescent  is  excreting 
the  spirochaetes  in  his  urine,  and  is  therefore  a  carrier. 


890  DISEASES    OE    THE    DIGESTIVE    SYSTEM. 

5.  Injection  of  urinary  sediment  into  the  peritoneal  cavity  of 
a  guinea  pig. 

This  method  has  frequently  been  followed  by  positive  results, 
and  should  be  regularly  practiced.  As  in  the  injection  of  blood, 
it  has  the  decided  advantage  that  positive  results  are  well  marked, 
causing  the  definite  pathological  changes  in  the  guinea  pig,  above 
referred  to. 

6.  Examination  of  tissues  obtained  at  necropsy  by  the  older 
method  of  Levaditi. 

B}'  this  method  the  spirochetes  may  frequently  be  demon- 
strated in  the  viscera,  especially  in  the  kidneys. 

(b)   In  rodents. 

Here,  as  in  the  detection  of  the  disease  in  man,  guinea-pig 
inoculation  is  the  method  of  choice  and  reliabilit}'.  The  rats 
should  preferably  be  taken  alive,  killed,  and  the  kidney  removed 
at  once,  with  precautions  not  to  contaminate  them.  The  kidneys 
should  then  be  emulsified  and  the  emulsion  injected  into  the  peri- 
toneal cavity  of  a  guinea  pig,  if  possible  using,  a  guinea  pig  for 
each  rat.  The  guinea  pigs  should  then  be  observed  for  at  least 
two  weeks.  If  the  Spirochccta  icterohcemorrhugicB  are  present  the 
pig  will  become  ill,  show  some  rather  variable  pyrexia,  become 
slightly  jaundiced,  collapse,  and  die  in  about  10  days,  and  at  post- 
mortem examination  will  show  the  marked  picture  of  jaundice 
and  hemorrhage  referred  to  above.  Spirochsetes  may  be  demon- 
strated in  the  tissues,  as  previously  indicated." 

TREATMENT. 

In  the  absence  of  a  specific  chemotherapeutic  agent  to  combat 
the  invading  parasites,  the  treatm.ent  should  be  symptomatic,  ac- 
cording to  directions  mentioned  under  Acute  Catarrhal  Jaundice. 


ACUTE    CHOLECYSTITIS. 

Catarrhal  or  suppurative  inflammation  of  the  gall-bladder 
may  be  the  result  of  infection  through  the  common  bile-duct 
or  through  the  blood-stream;  gall-stones  may  be  associated 
or  absent.  The  micro-organisms  commonly  found  are  the 
colon    bacillus,    typhoid    bacillus,    staphylococcus,    streptococcus, 


ACUTE  CHOLECYSTITIS.  891 

and  pneumococcus.  The  preliminary  symptoms  are  those  of 
indigestion,  followed  by  pain  over  the  gall-bladder  area,  with 
extension  of  the  pain  to  adjacent  parts  as  the  disease  pro- 
gresses. Nausea  and  vomiting  are  common  and  troublesome 
symptoms.  Fever  is  present  when  infection  is  caused  by  the 
streptococcus,  staphylococcus,  and  may  be  absent  in  colon 
bacillus  infection.  The  pulse  is  rapid  and  small,  the  respira- 
tion is  rapid,  and  conforms  to  the  costal  type,  and  the  abdomen 
is  more  or  less  rigid.  The  patient  appears  quite  prostrated. 
Palpation  reveals  tenderness  over  the  gall-bladder,  and  some- 
times a  pear-shaped  bulging  mass  may  be  outlined.  The 
leucocyte  count  may  be  normal  and  below  normal  in  bacillus 
colon  infections,  but  it  tends  to  become  high  when  the  fever 
is  marked.  This  condition  must  be  differentiated  from  ap- 
pendicitis occurring  high  in  the  abdomen  and  from  acute  in- 
testinal obstruction,  in  which  cases  pain  is  much  more  severe, 
and  comes  on  suddenly,  with  signs  of  more  or  less  general 
peritonitis.  Affections  of  the  gall-bladder  commonly  give 
symptoms  referable  to  its  intimate  anatomy. 

TREATMENT. 

The  patient  should  be  placed  in  bed,  and,  if  the  pain  is 
severe,  given  a  hypodermic  injection  of  %.  grain  (0.01620  Gm.) 
morphin.  Cases  of  acute  cholecystitis  of  catarrhal  type  may 
be  treated  precisely  as  catarrhal  cholecystitis  is  managed 
(g.^'.).  The  stomach  should  be  emptied  by  administering 
large  draughts  of  lukewarm  water  and  by  tickling  the  palate 
with  the  finger.  This  simple  measure  is  nearly  always  suc- 
cessful, and  should  be  repeated  until  the  stomach  contents  are 
completely  rejected.  Feeding  should  be  withheld  until  the 
patient  is  more  at  ease,  when  hot  lemonade  or  weak  tea  with 
crackers  or  toast  may  be  given.  To  this  may  be  added  strained 
barley  soup,  plain  broths,  and  dry  toast.  The  diet;  should  be 
gradually  increased  as  the  symptoms  subside.  To  aid  the 
abatement  of  the  catarrhal  symptoms  urotropin,  5  grains 
(0.324  Gm.)  three  times  a  day,  or  sodium  salicylate,  10  grains 
(0.650  Gm.)  three  times  a  day,  are  advocated.  If  the  vomiting 
or  retching  is  severe,  5  drops  (0.30  mil)  of  chloroform  on 
cracked  ice  Is  valuable ;  or  5  drops  (0.30  mil)  each  of  spirits  of 
chloroform  and  spirits  of  camphor  on  ice  should  be  given. 


892  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

The  dietetic  treatment  should  be  continued  for  several 
weeks  after  tenderness  of  the  gall-bladder  area  has  subsided. 

Repeated  attacks  of  cholecystitis  precede  gall-stone  inflam- 
mation. It  is  for  this  reason  that  patients  suffering  from  re- 
curring attacks  of  pain  in  the  gall-bladder  area  should  prolong 
their  treatment,  and  to  avoid  recurrence  should  maintain  a 
strict  dietar}^  The  bowels  should  be  regulated  by  an  occa- 
sional saline  purge,  by  the  constant  use  of  mineral  oil,  and  by 
enema  whenever  the  occasion  may  demand  it. 

GALL-STONES. 

Inflammation  of  the  gall-bladder  or  bile-ducts  may  result 
in  the  precipitation  of  the  inflammatory  products  which  when 
accumulated  become  organized  into  hard  masses  of  various 
shapes  and  sizes,  commonly  called  gall-stones.  These  may 
be  found  in  the  gall-bladder,  in  the  cystic  or  common  bile-duct, 
or  deep  in  the  structure  of  the  liver.  Cholecystitis  is  usually 
associated  with  or  may  precede  the  formation  of  gall-stones. 
The  typhoid  bacillus  and  the  colon  bacillus  are  chiefly  respon- 
sible for  the  inflammations  due  to  the  precipitation  of  the 
stones.  Among  the  predisposing  causes  are  obesity,  middle 
age,  female  sex,  sedentarv^  habits,  excesses  in  fat  and  starches, 
chronic  constipation,  habitual  tight  lacing,  pregnancy,  and 
pancreatic  disorders.  It  may  occur  in  adults,  and  even  in  child- 
hood. In  many  instances  there  is  a  histor}^  of  antecedent 
typhoid  fever. 

Stones  vary  in  size  from  a  grain  of  sand  to  that  of  an  egg", 
while  the  color  ranges  from  light  yellow  to  dark  green.  They 
are  largely  made  up  of  cholestrin,  bilirubin,  salts  of  calcium, 
potassium  and  sodium,  and  sometimes  traces  of  iron.  They 
mav  be  round,  oval,  faceted,  smooth  or  regular,  cuboid,  cylin- 
drical, hard,  or  soft. 

Gall-stones  do  not  always  produce  S3^mptoms.  Their  pre- 
sence is  indicated  only  when  their  passage  from  the  gall-blad- 
der through  the  ducts  is  obstructed  or  when  associated  w4th 
an  acute  or  chronic  cholecystitis. 

A  stone  impacted  in  the  bile-ducts  gives  rise  to  symptoms  o£ 
obstruction  and  irritation.  There  is  excruciating  pain  in  the 
right  hypochondriac  area,  ofttimes  referred  to  the  right 
shoulder  or  directly  backwards  toward  the  spine.     The  pa- 


GALL-STONES.  893 

tient  appears  exhausted,  there  is  quickening;  of  the  pulse,  with 
profuse  sweating  and  vomiting.  On  some  occasions  the  pa- 
tient will  shriek  out  in  pain,  following  which  there  is  syncope 
and  extreme  prostration.  There  may  or  may  not  be  any  pro- 
droma  preceding  the  attack.  Fever  may  be  present  or  absent, 
but  when  associated  with  g"all-stone  colic  it  ranges  from  101° 
to  102°  F.  (38.3°  to  38.8°  C).  If  the  common  bile-duct  is  oc- 
cluded, jaundice  becomes  a  conspicuous  symptom.  Chole- 
lithiasis, however,  is  associated  with  jaundice  in  only  about 
50  per  cent,  of  the  cases.  Stones  may  also  be  passed  without 
any  symptoms  of  pressure  or  obstruction. 

The  area  of  the  pain  is  situated  at  a  point  varying  from 
about  3  or  4  inches  {7.6  or  10.1  cm.)  below  the  xiphoid  car- 
tilage, and  about  the  same  distance  to  the  right  of  the  median 
line.  If  the  cystic  duct  is  obstructed,  a  distant  or  bulging 
mass  appears  in  the  gall-bladder  area,  which  is  the  distended 
gall-bladder.  In  cases  of  obstructive  jaundice,  the  hepatic 
area  may  be  enlarged  for  a  distance  of  several  inches  below 
the  costal  border.  The  areas  of  the  liver  and  gall-bladder  are 
sensitive  on  pressure.  Following  the  subsidence  of  the  jaun- 
dice and  after  the  passage  of  the  stone,  the  enlarged  hepatic 
area  recedes  to  normal.  The  attacks  of  colic  tend  to  recur, 
since  stones  are  usually  movable.  If  there  is  but  one.  attack, 
it  is  reasonable  to  suppose  that  there  has  been  but  one  stone 
of  such  size  as  to  cause  symptoms.  Gall-stone  colic  may  last 
from  a  few  hours  to  several  days,  and  the  pain  in  some  in- 
stances several  weeks.  Urinalysis  reveals  bile,  which  may  pre- 
cede the  occurrence  of  jaundice.  When  the  stones  are  small, 
the  hepatic  colic  is  of  mild  type,  causing  a  feeling  of  discom- 
fort and  distress.  The  diagnosis  of  gall-stones  is  often  very 
difficult.  Symptoms  of  indigestion,  and  occasionally  pain  over 
the  gall-bladder  and  liver  area  may  lead  tO'  suspicion.  When 
the  stones  become  impacted,  however,  the  diagnosis  is  readily 
confirmed.  The  bile  in  the  urine  is  a  warning  signal.  Stones 
passing  into  the  intestinal  tract  may  or  may  not  be  detected  in 
the  feces. 

TREATMENT. 

The  most  valuable  remedy  is  morphin  used  hypodermically, 
in  doses  of  ]/\  grain  (0.01620  Gm.),  repeated  in  a  half-hour  if 
necessary.     It  is  better  to  use  this  amount  of  the  narcotic  at 


894  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

first,  and  to  increase  if  necessary,  rather  than  to  give  an  initial 
large  dose.  As  an  accessory,  chloroform  may  be  inhaled  until 
the  effects  of  the  morphin  are  manifest.  Among  other  reme- 
dies may  be  mentioned  paregoric  in  teaspoonful  doses  (3.75 
mils),  repeated  two  or  three  times,  or  10  minims  (0.60  Gm.) 
of  deodorized  tincture  of  opium.  These  remedies,  however, 
taken  by  mouth  may  not  be  readily  absorbed,  and  are  not  in- 
frequently rejected  in  the  vomitus.  Morphin  used  hypoder- 
mically  is  the  remedy  par  excellence,  and  there  is  no  contraindi- 
cation to  its  use  in  severe  gall-stone  colic.  Hot  stupes  may  be 
applied  over  the  gall-bladder  area  with  great  relief :  hot  flax- 
seed poultices,  the  hot-water  bottle,  or  the  electric  pad.  After 
the  effect  of  the  morphin  has  subsided,  the  patient  may  ex- 
perience considerable  pain,  in  which  instance  paregoric  may 
be  given  in  teaspoonful  (3.75  mils)  doses  every  two  hours.  A 
valuable  prescription  consists  of  sodium  salicylate,  5  grains 
(0.324  Gm.),  and  codein  phosphate,  ^  grain  (0.00810  Gm.), 
every  three  hours. 

Following  the  attack  the  patient  will  naturally  have  little 
or  no  appetite.  This  is  a  distinct  advantage,  inasmuch  as  all 
solid  food  should  be  prohibited.  Hot  lemonade  or  hot  tea 
is  comforting.  After  the  patient  has  had  twenty-four  hours 
rest  in  bed  without  food,  the  bowels  should  be  moved  by  an 
enema  of  soap  suds  or  normal  salt  solution.  Strong  cath- 
artics are  contraindicated,  inasmuch  as  they  may  precipitate 
another  attack.  Enemas  when  given  too  early  or  given  care- 
lessly also  may  be  detrimental  for  the  same  reason.  When 
the  patient  is  more  at  ease,  broths  free  of  fat  are  permitted, 
and  plain  toast.  Cereals  with  milk  are  permitted,  among 
which  are  corn  flakes,  grape  nuts,  puffed  rice,  and  others.  The 
light  diet  should  be  continued  for  several  days.  All  fatty 
foods  are  to  be  omitted. 

CHRONIC    CHOLANGITIS    AND    CHRONIC 
CHOLELITHIASIS. 

Stones  lodged  in  the  gall-bladder  or  in  the  ducts  set  up  a 
chronic  catarrhal  inflammation  of  the  invaded  areas  attended 
with  a  group  of  symptoms  depending  upon  the  location  of  the 
calculi.  Repeated  attacks  of  pain  over  the  gall-bladder  area, 
attended  with  nausea,  vomiting,  tenderness,  and  gastro-intes- 


CHRONIC  CHOLANGITIS  AND  CHOLELITHIASIS.        895 

tinal  disorders  indicate  that  the  g'all-bladder  and  the  hepatic 
and  common  bile-ducts  are  the  seat  of  pathologic  changes. 
The  gall-bladder  may  be  enlarged  and  tender  as  the  result 
of  an  accumulation  of  mucus,  bile  or  stones.  When,  however, 
the  common  or  hepatic  ducts  are  affected,  a  catarrhal  inflam- 
mation is  set  up  which  causes  more  or  less  obstructive  symp- 
toms. Impaction  in  the  hepatic  duct  causes  a  general  cholan- 
gitis attended  with  exacerbations  of  acute  catarrhal  jaundice. 
Obstruction  of  the  common  duct,  however,  causes  enlargev 
ment  of  the  gall-bladder  and  liver  attended  with  jaundice, 
which  is  constant  and  intense,  or,  if  the  stone  be  movable,  in- 
termittent. The  ball-valve  action  of  the  stone  is  responsible 
for  the  changing  jaundice  and  the  febrile  elevations  and  re- 
cessions. Intense  itching  is  an  annoying  symptom.  Pain, 
referred  to  the  right  shoulder  or  to  the  back  is  paroxysmal, 
accompanied  by  chills,  fever  and  sweat.  During  the  interval 
of  attacks,  the  temperature  is  normal.  Infection  by  pathogenic 
micro-organisms  may  occur  during  the  course  of  chronic 
cholangitis  and  chronic  cholelithiasis,  causing  suppuration  of 
the  gall-bladder  or  a  suppurative  cholangitis.  The  character- 
istic symptoms — chills,  fever,  and  sweat — will  be  added  to 
those  already  mentioned.  Delay  in  surgical  procedure  may 
bring  on  a  fatal  septicemia. 

TREATMENT. 

The  treatment  of  gall-stones  is  surgical.  During  the  at- 
tacks of  colic  the  medical  measures  already  described  are  indis- 
pensable. Between  the  attacks,  however,  attempts,  should  be 
made  to  abate  the  catarrhal  inflammation  of  the  liver  and 
ducts  and  to  encourage  a  return  of  normal  function.  Dietetic 
treatment  in  this  respect  is  the  determining  factor  in  aborting 
future  attacks.  The  acute  exacerbations  common  in  gall- 
stones call  for  light  diet — soups  strained  of  fat,  milk,  butter- 
milk, skim  milk,  toast,  crackers,  hot  lemonade,  and  tea.  It  is 
generally  recommended  that  acid  food  be  avoided.  While 
this  is  true  of  tomatoes,  vinegar,  salad  dressing,  pickles,  and 
other  spiced  foods,  the  juice  of  sweet  oranges  used  with  shaved 
ice  is  quite  palatable  and  harmless.  Fatty  foods;  however,  are 
forbidden.  During  the  intervals  between  attacks  all  fried 
foods   should   be   stricken   from  the   menu,   but   boiled    soup 


896  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

meats,  chicken,  and  tender  veal  are  permitted.  Custards,  jun- 
ket, tapioca  pudding,  floating  island,  and  vanilla  ice  cream  all 
are  to  be  allowed. 

Among  the  vegetables  permitted  are  peas,  beans,  asparagus 
tips,  a  small  amount  of  butter,  spinach,  and  carrots.  Patients 
troubled  with  hyperchlorhydria  should  drink  large  quantities 
of  water,  either  pure  or  containing  alkalies,  with  a  view  to  neu- 
tralizing the  excess  acids.  Effervescent  phosp'hate  of  soda,  1 
teaspoonful  (3.9  Gm.)  in  half  a  glass  of  hot  water  before 
breakfast  or  given  three  times  a  day,  tends  to  stimulate  the 
flow  of  bile,  cleanses  the  stomach  of  retained  mucus  and  food 
and  renders  the  bowel  movements  soft  and  effective.  Among 
the  natural  waters  recommended  are  Carlsbad,  Vichy,  Xeu- 
enahr.  and  Bedford.  A'cttmann-""!  recommends  the  following 
formula : 

Magnesii  sulph Sij        60.0. 

Sodii  sulphatis   oj         30.0. 

Sodii  bicarbonates   5iiss     10.0. 

M.  S. :  One  teaspoonful  (3.75  mils)  in  glass  of  hot 
water,  one-half  hour  before  breakfast  and  one- 
half  hour  before  dinner  and  supper. 

Too  great  emphasis  cannot  be  placed  upon  the  value  of  rest 
in  the  treatment  of  chronic  cholecystitis  and  cholelithiasis. 
During  the  attacks  patients  should  remain  in  bed  as  long  as 
there  is  tenderness  over  the  liver  area.  Unusual  physical 
activity  may  precipitate  an  attack.  It  is,  therefore,  advisable 
that  patients  during  normal  intervals  should  avoid  active 
athletics. 

Much  has  been  said  regarding  the  value  of  treatment  at 
Carlsbad,  where  good  results  have  been  attributed  to  the 
routine  measures,  to  the  change  of  scene,  and  to  careful  dis- 
cipline under  the  supen'ision  of  experts.  It  is  believed,  how- 
ever, that  just  as  good  results  could  be  obtained  at  home  in 
the  many  resorts  throughout  the  United  States.  Southern 
California  is  a  most  suitable  place  for  sojourn,  and  the  equi- 
table climate  is  most  desirable.  If  just  as  much  publicity 
were  given  to  resorts  in  the  United  States  as  have  been  given 
to  those  abroad,  it  is  believed  that  just  as  good  or  even  better 
results  could  be  obtained. 

During  the  attacks  of  pain,  local  application  of  hot  Epsom 


CHRONIC  CHOLANGITIS  AND  CHOLELITHIASIS.       897 

salt  stupes  or  hot  flaxseed  poultices  over  the  gall-bladder  area 
give  much  relief.  When  the  temperature  is  high,  it  is  often 
advisable  to  alternate  the  hot  stupe  with  cold,  especially  dur- 
ing the  wann  months  when  cold  is  best  tolerated.  An  en- 
larged gall-bladder  and  liver  may  recede  under  constant  appli- 
cation of  hot  compresses  over  the  upper  half  of  the  abdomen 
continued  at  least  for  twenty-four  hours.  Colonic  irrigation 
Avith  salt  solution  is  sometimes  advisable  during  the  exacerba- 
tions. Continued  and  exaggerated  symptoms,  however,  call 
for  operative  interference. 

Cholelithiasis  considered  alone  is  a  surg"ical  disease.  Many 
cases  may  incidentally  get  well  under  persistent  medical  care 
and  supervision,  but  with  our  advanced  methods  of  surgery, 
asepsis  and  expert  nursing,  the  removal  of  gall-stones  and  the 
drainage  of  the  gall-bladder  during  the  early  stage  of  the  dis- 
ease promises  prompt  relief  and  freedom  from  complications. 

Attempts  to  remove  or  dissolve  stones  by  the  internal 
administration  of  drugs  have  proved  futile.  The  use  of  strong 
purgatives  to  expel  the  stones  is  also  without  avail.  During 
the  intervals  of  attacks,  good  results  may  be  obtained  by  order- 
ing a  prescription  composed  of  ox-gall,  1  grain  (0.065  Gm.)  ; 
sodium  salicylate  and  sodium  succinate,  each  2  grains  (0.130 
Gm.),  in  capsule,  three  times  a  day.  These  drugs  tend  to 
defer  the  attacks  and  lessen  their  frequency.  They  do  not, 
however,  remove  the  causative  agents,  and  sooner  or  later  the 
attacks  become  so  annoying  and  disappointing  to  the  patient 
that  surgical  intervention  is  indicated.  Olive  oil  has  its  value 
in  relieving  the  gastric  symptoms,  for  its  use  lubricates  the 
bowel  and  softens  the  stools.  It  does  not,  however,  remove 
predisposing  causes  or  precipitating  agents  of  gall-stones. 

When  there  is  continuous  loss  of  weight,  loss  of  appetite, 
and  general  physical  and  mental  depression,  medical  treatment 
does  little  or  no  good.  Continued  attacks  of  gall-stones  bring 
about  chronic  changes  in  the  liver  and  stomach  and  seriously 
interfere  with  the  patient's  activities  of  life,  and  in  such  in- 
stances, after  medical  treatment  for  two  or  three  months  with- 
out marked  improvement,  operation  should  be  advised.  Much 
confusion  exists,  however,  among  surgeons  and  internists  as 
to  the  best  time  for  operation.  Some  urge  immediate  inter- 
ference, while  others  prescribe  a  lengthy  medical  course,  re- 


DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

sorting  to  surgical  means  only  when  urgent  indications  arise. 
Each  case,  however,  presents  its  own  problem,  and  the  decision 
rests  with  the  circumstances  surrounding  the  patient  and  the 
facilities  for  carrying  out  the  full  details  of  medical  care. 

AVhen  the  gall-bladder  becomes  acutely  inflamed  and  there 
is  pain,  fever,  and  rigidity  extending  beyond  the  gall-bladder 
area,  with  threatened  general  peritonitis,  or  should  the  S3aTip- 
toms  suggest  suppuration,  surgical  interference  is  of  course 
apparent.  Chronic  obstruction  of  the  common  duct  with  sep- 
tic complications  also  calls  for  surgical  measures.  Among 
other  complications  demanding  the  surgeon's  attention  are 
perforation  and  gangrene  of  the  gall-bladder,  and  hydrops  and 
adhesions  causing  indefinite  symptoms. 

jMedical  treatment  alone  should  be  limited  to  simple 
catarrhal  cholecystitis,  cholelithiasis  with  mild  infrequent 
attacks  of  colic  or  without  marked  physical  signs,  and  to  cases 
which  respond  readil}^  to  common  therapeutic  measures. 

CIRRHOSIS  OF  THE  LIVER. 
(Sclerosis  of  the  Liver;  Interstitial  Hepatitis.) 

The  term  cirrhosis  of  the  liver  is  commonly  used  to  indi- 
cate a  chronic  disease  of  this  organ  characterized  by  the  de- 
posit of  an  excess  of  connective  tissue.  Irritation  of  the  liver 
continued  over  a  great  length  of  time,  regardless  of  the  agency 
or  source,  is  accompanied  by  multiplication  of  the  round  cell 
tissue  at  the  expense  of  the  liver  cells,  encroaching  upon  the 
blood-vessels  and  bile-ducts  in  such  a  way  as  to  obstruct  their 
normal  circulation,  as  the  result  of  which  there  is  produced  a 
series  of  symptoms,  both  local  and  general. 

Three  types  of  cirrhosis  are  generally  recognized — atrophic, 
hypertrophic,  and  biliar\\  From  clinical  evidence,  however, 
there  is  need  to  mention  but  two  main  types,  of  which  there 
may  be  gradations  having  characteristics  of  both.  These 
clinical  types  are : 

1.  Portal  cirrhosis,  characterized  by  the  excess  formation 
of  connective  tissue  around  the  portal  veins  in  such  a  manner 
as  to  restrict  their  circulation,  damming  back  the  blood  into 
the  spleen,  stomach  and  intestines. 

2.  Biliarv  cirrhosis,  characterized  by  inflammatory  changes 


CIRRHOSIS  OF  THE  LIVER.  899 

and  thickenint^  of  the  walls  of  the  Ijile-diicts,  causing-  the  l)ile 
circulation  to  become  impeded. 

Of  the  portal  x'ariety,  two  forms  may  be  described — atrophic, 
or  Laennec's,  and  hypertrophic,  or  Hanot's  cirrhosis.  The 
former  is  the  more  common.  The  liver  is,  in  the  early  stage 
of  Laennec's  cirrhosis,  enlarged  or  normal  in  size,  but  later  it 
becomes  much  smaller  than  normal.  The  capsule  is  thickened, 
presenting  a  granular  appearance  under  the  surface.  The  liver 
is  firm  to  touch  and  altered  in  shape.  On  cutting",  it  resists 
the  knife.  The  surface  of  the  skin  exhibits  a  hobnailed  ap- 
pearance, caused  by  the  projection  of  yellow^ish  areas  of  liver 
cells  surrounded  by  grayish  white  bands  of  connective  tissue.. 
Microscopically,  there  is  an  increase  of  connective  tissue  about 
the  portal  veins  and  a  crowding  together  of  liver  cells. 

In  contrast  tO'  this  hypertrophic  cirrhosis  exhibits  its  con- 
nective tissue  change  in  the  peripheral  zones  of  the  acini  ex- 
tending into  the  intralobular  connective  tissue,  constricting 
and  obstructing  the  biliary  passages.  The  liver  is  enlarged, 
extending  several  fingers'  breadth  below  the  costal  border.  It 
presents  a  mottled  yellowish-g'reen  appearance. 

Mayo'^-  claims  that  he  has  never  seen  a  case  of  Hanot's 
cirrhosis.  He  believes  that  this  type  of  cirrhosis  has  no  patho- 
logic basis  and  little  clinical  evidence  to  support  its  existence. 
He  contends  that  a  large  majority  of  the  cases  that  have  been 
called  hypertrophic  or  Hanot's  cirrhosis  are  either  hemolytic 
icterus  or  the  ordinary  type  of  biliary  cirrhosis.  While  typical 
biliary  cirrhosis  and  typical  portal  cirrhosis  exist  and  are  well 
defined  as  such,  it  is  easy  to  deduct  that  atypical  or  mixed 
car.es  are  found,  and  that  connective  tissue  may  be  in  excess 
locally  or  throughout  the  liver. 

Biliary  cirrhosis  results  from  chronic  stasis  of  bile  in  the  ducts 
about  the  bile-ducts,  the  walls  of  which  are  thickened  and  the 
lumena  constricted ;  microscopically,  it  resembles  the  hyper- 
trophic variety.  The  walls,  however,  are  more  deeply  bile- 
stained.  The'  characteristic  changes  consist  of  spots  of 
necrosis  in  the  peripheral  zones  of  the  acini.  Later  these  areas 
are  replaced  by  new  connective  tissue,  and  new  bile-ducts  ap- 
pear in  the  intralobular  spaces. 

Local  areas  of  cirrhosis  may  occur  in  tuberculosis,  cancer, 
and  syphilis. 


900  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

Both  portal  and  biliary  cirrhosis  may  he  associated'  with 
an  enlarged  spleen.  In  51  cases  of  splenic  anemia  reported  by 
Wm.  J.  i\Iayo,  in  which  the  enlarged  spleen  was  removed,  the 
relief  to  the  portal  circulation  was  immediate.  The  portal  ob- 
struction and  ascites  disappeared.  The  evidence  here  points 
to  the  fact  that  the  poisonous  products  were  carried  to  the 
liver  from  the  spleen,  their  nature  probably  being  that  of  a 
protein  derivative  filtered  from  the  blood. 

Anv  irritant  which  reaches  the  liver  from  the  portal  or 
hepatic  circulation  or  through-,the  bile-ducts  may,  after  acting 
for  a  sufficient  length  of  time,  result  in  a  reactive  stimulation 
of  the  connective  tissue  framework  of  the  liver.  Alcohol  is  the 
most  frequent  cause  of  fibrosis  in  portal  cirrhosis.  The  degree 
of  connective  tissue  change  is  in  direct  proportion  to  the 
amount  and  strength  of  the  liquors  taken.  Highly  spiced  food 
mav  also  influence  the  excessive  production  of  fibrous  tissue. 
In  cases  of  chronic  autointoxication  and  in  chronic  digestive 
disorders,  cirrhosis  of  the  liver  may  be  the  resultant  factor. 
Syphilis  (especially  congenital),  diabetes,  gout,  cancer,  tuber- 
culosis, and  chronic  forms  of  malaria  may  be  accompanied  by 
interstitial  thickening  of  the  liver.  Cardiac  diseases  with  in- 
sufficiency of  the  circulation  are  found  associated  with  second- 
ary cirrhosis.  Splenic  diseases  may  also  be  accompanied  by 
changes  in  the  liver. 

Biliary  cirrhosis  is  usually  associated  with  gall-stones, 
more  especially  when  there  is  chronic  obstruction  in  the  com- 
mon bile-duct.  Jaundice  is  a  common  feature.  The  removal 
of  the  stones  or  drainage  of  the  gall-bladder  does  not  always 
effect  a  cure,  since  some  concretions  may  persist  in  the  small 
bile-ducts.  The  damage  caused  by  the  stones  has  already  been 
done,  and  thickening  of  the  ducts  has  occurred  at  the  expense 
of  their  lumena. 

Another  type  of  biliars-  cirrhosis  may  result  from  infection 
of  the  gall-ducts  and  gall-bladder  with  the  streptococcus  and 
colon  bacillus.  Chronic  infection  of  the  biliar\-  passages  may 
be  complicated  by  a  chronic  pancreatitis. 

In  hvpertrophic  cirrhosis  there  is  frequently  an  absence  of 
definite  cause.  It  may  occur  in  children  and  in  young  adults 
following  infectious  diseases.  It  is  likely  that  this  disease  has 
often  been  confused  with  biliarv  cirrhosis. 


CIRRHOSIS  01'  Till-:  liver.  901 

The  disease  may  exist  for  years  without  any  special 
syuiptoms  referable  to  the  liver.  When,  however,  the  portal  cir- 
culation becomes  impeded,  a  cham  of  symptoms  limited  to 
the  abdomen  arise.  Among  the  early  signs  are  anorexia,  loss 
of  appetite,  loss  of  weight,  and  general  gastro-intestinal  dis- 
orders such  as  constipation,  indigestion,  and  jaundice.  As  the 
portal  circulation  becomes  obstructed,  the  patient  complains 
of  morning  nausea  and  sometimes  vomiting  of  blood.  The 
stools  also  may  contain  evidence  of  slight  bowel  hemorrhages. 
A  sense  of  fullness  and  pain  may  be  complained  of  over  the 
hepatic  area.  As  the  obstruction  increases,  it  causes  the  veins 
over  the  surface  of  the  abdomen  to  become  enlarged  and 
prominent.  This  is  due  to  the  compensatory  circulation  estab- 
lished between  the  internal  mammary  and  the  superficial  epi- 
gastric veins.  Loss  of  weight  progresses  as  the  degree  of  ob- 
struction increases ;  the  cheeks  become  hollow  and  the  com- 
plexion is  sallow ;  the  face  has  a  pinched  expression.  Ascites 
gradually  develops,  distending  the  abdomen,  the  walls  of 
which  become  taut  and  the  skin  shiny.  General  symptoms  of 
toxemia  soon  develop,  accompanied  by  delirium,  convulsions, 
and  later  by  coma.  Secondary  anemia  usually  develops,  some- 
times to  an  extreme  degree.  The  disease  is  afebrile,  although 
occasionall}^  the  temperature  ranges  as  high  as  from  100°  to 
102°  F.  {37.7°  to  38.8°  C).  Urine  analysis  shows  an  in- 
creased specific  gravity,  a  diminished  amount  of  urea,  occa- 
sionally the  presence  of  bile,  and  in  cases  associated  with 
nephritis  a  variable  quantity  of  albumin  and  tube  casts. 

On  physical  examination  the  abdomen  is  found  to  be  dis- 
tended, the  veins  prominent,  and  the  skin  of  a  yellowish 
tinge.  The  distention  ofttimes  makes  it  impossible  to  outline 
the  lower  border  of  the  liver,  but  after  paracentesis  its  nodu- 
lar edge  can  be  felt  at  the  costal  border.  AVhen  outlining"  the 
liver  bv  percussion,  its  vertical  enlargement,  ^vhich  is  nor- 
mally about  4  inches  (10.1  cm.)  in  length  may  be  either 
diminished  or  increased.  This  variation  in  size  is  accounted 
for  bv  the  fact  that  the  early  stages  of  atrophic  cirrhosis  may 
be  accompanied  by  the  preliminary  hypertrophy. 

The  liver  in  hypertrophic  cirrhosis  is  enlarged,  as  detected 
by  percussion.  As  to  the  symptoms,  jaundice,  accompanied  by 
gastro-intestinal  disorders,  is  constant.     There  may,  however, 


902  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

be  an  enlargement  of  the  liver  long  before  an}-  constitutional 
symptoms  manifest  themselves.  As  the  disease  progresses  the 
jaundice  increases,  with  varying  amount  of  fever,  periodic  at- 
tacks of  pain  resembling  hepatic  colic,  hemorrhages  into  the 
skin  and  mucous  membrane,  and  profound  prostration.  In 
some  instances  fever  may  be  entirely  absent.  Bile  is  found  in 
the  urine,  together  with  albumin  and  casts.  The  spleen  may 
be  enlarged,  and  ascites  is  rare. 

The  svmptoms  of  biliury  cirrJiosis  are  those  already  men- 
tioned under  Chronic  Obstruction  of  the  Bile-ducts.  Jaundice 
is  prominent  and  much  more  intense  than  in  the  hypertrophic 
form.  Intermittent  fever  is  frequently  obser\-ed.  Gall-stones, 
stricture  of  the  common  bile-duct,  and  obstruction  by  tumors 
or  other  agencies,  will  present  their  respective  symptoms  in 
addition  to  those  of  biliar\'  cirrhosis. 

TREATMENT  OF  CIRRHOSIS  OF  THE  LIVER. 

In  the  early  stage  efforts  should  be  made  to  remove  the 
existing  causes,  as  already  mentioned  under  the  discussion  of 
the  etiology,  to  relieve  the  prevailing  gastro-intestinal  symp- 
toms, and  to  adopt  a  routine  diet  which  will  relieve  the  liver 
of  its  imperfect  functions,  and  stay  the  further  development  of 
the  disease.  Alcoholic  beverages  should  be  forbidden. 
Highly  spiced  and  seasoned  foods  must  be  avoided,  so  that 
salt  herring,  spices,  beef,  mustard,  pepper,  horseradish, 
AA'orcestershire.  paprika,  catsup,  and  other  acrid  condiments 
must  be  forbidden.  For  the  mucous  gastritis  which  often  ac- 
companies the  active  stage  of  cirrhosis,  a  teaspoonful  (3.75 
Gm.)  of  efifervescent  phosphate  of  soda  in  a*glass  of  hot  water 
should  be  taken  one-half  hour  before  breakfast.  This  tends  to 
wash  out  the  accumulated  mucus  and  favors  a  laxative  move- 
ment of  the  bowels.  If  there  is  a  great  deal  of  gaseous  dis- 
tention, sodium  bicarbonate  or  magnesium  oxide  should  be 
substituted.  Calomel  given  in  small  doses  for  several  days 
and  even  weeks  mav  be  of  material  assistance.  About  ^q  grain 
(0.01080  Gm.)  given  three  times  a  day  exerts  a  beneficial 
effect  both  upon  the  function  of  the  liver  and  the  intestinal 
tract.  This  statement  is  made  in  spite  of  the  recent  investi- 
gation which  claims  that  calomel  has  really  no  listinct 
chologogic  effect. 


ClRRllUSJS  Ul'  THE  LIVER.  903 

A  great  deal  has  been  said  in  favor  of  treating  chronic 
liver  complaints  in  places  distant  from  the  patient's  home. 
It  is  believed,  however,  that  this  country  offers  a  sufficient 
number  of  resorts,  both  in  the  East  and  in  the  West,  where 
proper  and  effective  systematic  treatment  may  be  procured, 
and  where  the  desired  rnental  diversion  and  physical  rest  may 
be  obtained.  The  present  world-wide  conflict,  which 
makes  it  impossible  to  obtain  treatment  in  other  countries, 
will  prove  to  our  satisfaction  that  cases  of  liver  complaint  will 
make  just  as  many  recoveries  from  home  treatment  as  in  for- 
eign resorts  across  the  Atlantic.  The  constant  use  of  spring 
waters  has  a  beneficial  effect  in  washing  out  the  stomach  and 
intestines,  reduces  the  toxemia  and  stimulates  the  function  of 
the  liver  and  intestines. 

In  cases  of  cirrhosis  caused  by  syphilis,  iodids  are  essen- 
tial. These  can  be  increased  in  quantity  to  the  stage  of  toler- 
ance, being  mindful,  however,  not  to  cause  derangement  of 
the  digestion.  Even  in  non-specific  cases  iodids  are  recom- 
mended. The  bowels  should  be  kept  well  regulated  by  the 
occasional  use  of  milk  of  magnesia,  sodium  phosphate,  or 
citrate  of  magnesia. 

The  diet  plays  a  very  important  and  conspicuous  part  in 
the  treatment.  All  fats  and  most  acids  are  to  be  avoided. 
This  does  not  preclude  such  foods  as  milk  and  its  derivatives, 
cream,  butter,  buttermilk,  and  skim  milk,  all  of  which  may  be 
taken  with  advantage.  A  milk  diet  alternated  with  butter- 
milk is  very  desirable.  One  quart  (1  1.)  of  rich  milk  and  an 
equal  quantity  of  cream  buttermilk  should  be  taken  daily.  It 
is  an  advantage  to  stop  all  other  feeding  for  one  or  two  days 
and  place  the  patient  on  a  milk  and  buttermilk  diet,  later  add- 
ing butter  crackers,  cereals  (cornflakes,  cream  of  wheat, 
shredded  wheat,  grapenuts),  milk  and  eggs,  egg  custard, 
tapioca  puddings,  gelatin,  junket,  and  ice  cream.  The  sour 
fruits  such  as  peaches,  plums,  and  pine-apple  tend  to  exagger- 
ate the  gastric  disturbances.  The  juice  of  sweet  oranges  taken 
with  cracked  ice  is  often  quite  acceptable.  All  sour  vegetables 
should  be  avoided.  Among  the  meats,  boiled  beef,  stewed 
chicken,  and  roast  veal  may  be  taken.  Pork,  bacon,  smoked 
meats,  shell-fish,  and  fat  fish  are  unsuitable. 

Not  only  is  the  dietar}^  to  be  continued  regularly  but  con- 


904  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

tinuously  until  the  gastro-intestinal  symptoms  are  in  abey- 
ance, the  bowels  regular,  the  urine  reduced  to  its  normal 
specific  gravity,  the  urea  contents  made  normal  and  the 
subicteroid  complexion  disappears. 

Portal  obstruction  attended  with  ascites  calls  for  a  removal 
of  the  accumulated  fluid  and  the  prevention  of  its  return. 
When  the  fluid  is  slight,  purgation  by  the  use  of  compound 
jalap  powder,  30  grains  to  1  dram  (1.9  to  3.9  Gms.),  repeated 
to  obtain  the  desired  effect,  may  be  sufficient.  Salts  of  mag- 
nesium, Glauber's  salts,  potassium  bitartrate,  and  similar 
preparations  may  be  used  advantageously  during  the  early 
stage  of  insufficiency  of  the  portal  circulation,  being  careful 
not  to  exhaust  the  patient.  Diuretics  are,  however,  preferable. 
An  efifective  capsule  having  a  decided  diuretic  action  consists 
of  1  grain  (0.065  Gm.)  each  of  powdered  digitalis,  powdered 
squills,  calomel,  and  caifein  citrate;  to  be  effective  1  capsule 
should  be  administered  every  three  hours.  If  the  respiration 
and  the  comfort  of  the  patient  is  disturbed  by  the  accumulated 
fluid,  it  should  be  removed  by  tapping.     (See  p.  969.) 

Following  aspiration  of  the  fluid  in  the  abdomen,  the  pa- 
tient should  be  placed  on  a  salt-free  diet  in  the  effort  to  avoid 
recurrence  of  the  ascites.  At  first  the  patient  should  abstain 
from  the  use  of  all  solid  foods.  The  diet  should  be  prepared 
in  such  a  way  as  to  avoid  all  possible  use  of  salt.  Such  a  salt- 
free  diet  should  be  continued  to  the  point  of  tolerance,  at 
which  time  salt  may  be  added  in  small  quantities.  A  diet  of 
milk,  buttermilk  and  skim  milk,  given  alternately,  is  advo- 
cated in  the  early  stages  of  cirrhosis.  Such  a  dietary  furnishes 
large  quantities  of  water,  which  produces  diuresis  and  renders 
the  stools  soft  and  free. 

The  portal  circulation  is  activated  by  the  daily  administra- 
tion of  mineral  waters,  milk  of  magnesia,  phosphate  of  soda, 
or  compound  jalap  powder.  Calomel  in  small  doses  ma}^  be 
given  over  a  period  of  several  weeks.  These  drugs  tend  to 
keep  the  abdomen  free  of  excess  of  fluids. 

Surgical  measures  have  been  advocated  by  Talma  and 
Drummond  for  diverting  or  short-circuiting'  the  portal  cir- 
culation by  establishing  a  direct  communication  between  the 
portal  and  systemic  venous  circulation.  It  remains  to  be 
proved,  however,  whether  this  procedure  is  practicable. 


ABSCESS  OF  THE  LIVER.  905 

The  terminal  stage  of  insufficiency  of  tiie  portal  circula- 
tion is  manifested  by  toxic  symptoms,  which  are  either  renal, 
hepatic  or  iiitestinal,  or  a  combination  of  all.  Delirium  and 
coma  are  the  terminal  symptoms,  and  the  disease  may  termi- 
nate in  a  fatal  hemorrhage.  It  should  be  remembered  that 
persons  in  apparently  good  health  suddenly  may  develop  a 
serious  hemorrhage  from  the  stomach  as  the  result  of  portal 
cirrhosis  which  had  not  previously  been  discovered.  Hemate- 
mesis  may  be  an  early  symptom  due  to  congestion  and  stasis 
of  the  venous  circulation  about  the  cardiac  end  of  the 
esophagus. 

Hemorrhage  from  the  stomach  or  bowel  demands  that  the 
patient  be  placed  in  bed  in  a  quiet  room.  Food  is  withdrawn 
entirely  and  an  ice-bag  placed  upon  the  abdomen.  After  the 
patient  is  quiet  and  the  hemorrhage  has  ceased  for  twenty-four 
hours,  rectal  feeding  should  be  commenced.  After  another  day 
milk  may  be  given  by  mouth,  together  with  such  other  liquids 
as  the  individual  case  will  permit.  The  occurrence  of  hemor- 
rhage in  the  gastro-intestinal  tract  renders  the  prognosis  ex- 
tremely grave.  Nephritic  complications  should  be  treated 
along  rational  lines.  When  delirium  occurs,  hot  packs  com- 
bined with!  the  hypodermic  use  of  pilocarpin  and  the  internal 
administration  of  cathartics  may  bring  about  some  relief. 
When  the  symptoms  of  extreme  toxemia  occur,  they  are  indi- 
cative of  a  fatal  termination,  in  which  instance  efforts  should 
be  made  to  make  the  patient  as  comfortable  as  possible. 

ABSCESS  OF  THE  LIVER. 

The  liver  may  be  the  seat  of  single  or  multiple  abscesses 
as  the  result  of  invasion  of  pathogenic  micro-organisms 
througii  the  portal  system,  bile-ducts,  general  blood-stream, 
and  occasionally  through  the  lymphatics.  When  a  single 
abscess  occurs,  it  usually  affects  the  right  lobe,  and  is  either 
deep-seated  or  superficial.  The  abscess  wall  may  be  thin  or 
thick,  depending  upon  the  severity  of  the  infection  and  the 
time  during  which  it  has  existed.  The  surrounding  area  is 
injected,  and  there  is  considerable  amount  of  round-cell  infil- 
tration, and  more  or  less  new  connective  tissue.  The  contents 
also  vary  according  to  the  type  of  infection,  its  severity  and 


906  DISEASES   OF   THE   DIGESTIVE   SYSTEM, 

*its  duration.  It  varies  from  a  grayish-white  to  a  reddish- 
brown  color,  and  its  consistenc}^  may  be  either  viscid  or  quite 
fluid  in  character.  When  multiple  abscesses  occur,  the  sur- 
face of  the  liver  is  studded  with  small  elevated  yellowish 
tubercles  beneath  the  capsule.  Section  of  the  liver  reveals 
small  abscesses  throughout  its  structure.  Thrombosis  in  some 
of  the  portal  vessels  may  be  found.  Infection  resulting  from 
gall-stones  and  obstructed  bile  gives  added  evidences  of  these 
respective  conditions.  The  hepatic  cells  are  in  a  state  of 
parenchA'matous  degeneration  and  there  is  general  turgescence 
of  the  circulation.  The  abscess  cavities  are  filled  with  pus, 
necrotic  tissue  and  bacteria.  The  latter  sometimes  ma^-  be 
entirel}'  absent.  The  smaller  blood-vessels  ma}"  be  filled  with 
emboli. 

Suppuration  of  the  liver  may  result  from  traumatism,  the 
presence  of  gall-stones,  and  a  secondary  infection  from  gas- 
tric ulcer,  appendicitis,  typhoid  fever  and  dysenter3^  Infec- 
tions in  other  parts  of  the  body  may  be  complicated  by  ab- 
scess of  the  liver,  such  as  long-standing  disease  of  the  bones, 
injuries  of  the  soft  parts,  and  occasionally  following  scalp 
wounds.  Liver  abscess  may  also  result  from  parasitic  in- 
vasion by  flukes,  ascaris,  ankylostoma,  tsenia  and  oxyuris. 
Alcoholism  and  malaria  are  predisposing  factors. 

Tropical  abscesses  may  exist  with  few  or  no  signs  refer- 
able to  the  liver,  but  are  attended  by  diarrheal  disturbances. 
Suspicion  of  abscess  may  always  be  entertained  when  ameba 
are  found  in  stools.  Abscess  of  the  liver  occurs  at  ages  vary- 
ing from  7  to  50.  but  most  commonlv  from  20  to  30.  About 
nine-tenths  of  them  occur  among  men.  The  abscesses  may  be 
small  or  large,  some  4  centimeters  in  diameter,  and  others 
implicating  the  whole  of  the  right  lobe  of  the  liver,  containing 
a  liter  or  more  of  pus.  The  contents  of  a  chronic  abscess  is 
a  thick  viscid  reddish-brown  foul  pus,  in  some  instances 
containing  shreds  of  liver  tissue. 

The  symptoms  of  abscess  are  very  much  like  those  of  sup- 
purations elsewhere,  with  the  added  symptoms  referable  to  the 
liver.  There  is  pain  and  tenderness  over  the  hepatic  area, 
which  becomes  exaggerated  upon  changing  posture  and  on 
pressure.  IMultiple  abscesses  may  produce  few  or  no  physical 
signs.    A  single  abscess,  however,  produces  quite  characteris- 


ABSCESS  OF  THE  LIVER.  907 

tic  symptoms.  There  is  a  Ijulging-  of  the  ribs  over  the  hepatic 
area,  and  the  overlying  skin  is  reddened  and  inflamed.  A  deep- 
seated  abscess  is  less  plainly  visible  externally.  The  lower 
l)order  of  the  liver  extends  several  fingers'  breadth  below  the 
costal  border.  Palpation  reveals  tenderness  and  in  some  in- 
stances fluctuation  in  the  midclavicular  line.  The  area  of 
hepatic  dullness  is  increased  upward  both  in  the  midclavicular 
line  and  midaxillary  line,  and  can  be  traced  to  the  angle  of  the 
scapula. 

Acute  abscesses  are  attended  by  a  sharp  rise  in  tempera- 
ture ranging  from  103°  to  104°  F.  (39.4°  to  40°  C),  and  may 
be  ushered  in  by  a  severe  chill.  The  fever  is  hectic,  resembling 
tertian  and  quartan  malaria,  attended  by  chills,  fevers,  and 
sweats.     In  chronic  cases  little  or  no  fever  is  present. 

Large  abscess  may  perforate  through  the  abdominal  wall 
into  the  pleura  cavity,  bronchi,  pericardium,  stomach,  intes- 
tines, or  peritoneal  cavity,  and  produce  complicating  symptoms 
accordingly.  When  rupture  takes  place  into  the  lungs,  there 
is  cough,  expectoration  of  an  anchovy  sauce-like  muco-pus. 
There  are  also  symptoms  of  a  complicating  empyema. 

Abscess  of  the  liver  produces  general  symptoms  character- 
ized by  loss  of  flesh  and  strength,  gastro-intestinal  disorders, 
constipation  alternating  with  diarrhea,  and  an  icteroid  tinge 
of  the  skin.  The  entameba  histolytica  may  be  found  in 
the  stools.  Pressure  of  the  abscess  upward  compresses  the 
lung  tissue,  causing  cough,  expectoration,  dullness,  broncho- 
vesicular  breathing  and  crepitant  rales  at  the  base  of  the  right 
lung.  Splenic  enlargement  is  a  common  accompanying  physi- 
cal sign.  Severe  toxic  symptoms  resulting  from  infection  of 
the  liver  may  bring  about  a  general  septicemia  or  toxemia 
manifested  by  severe  headache,  backache,  and  pyrexia, 
delirium,  tremor,  stupor,  and  coma. 

TREATMENT. 

Liver  abscess  should  be  treated  in  the  same  manner  as 
abscess  in  other  parts  of  the  body.  Early  and  free  incision 
with  a  view  of  draining  the  infectious  products  is  the  first 
indication.  There  are,  however,  many  medical  measures  which 
can  be  adopted  preparator}^  to  surgical  procedure,  especially 
in  cases  of  multiple  abscess  where  drainage  is  not  feasible. 


908  DISEASES    OF   THE    DIGESTIVE   SYSTEM. 

The  temperature  can  be  reduced  by  tepid  sponging,  the  appli- 
cation of  an  ice-bag.  and  the  internal  administration  of  quinin. 
Hot  stupes  or  a  hot-water  bottle  over  the  hepatic  area  may 
tend  to  make  the  patient  more  comfortable.  An  acute  abscess 
always  should  be  evacuated  as  early  as  possible.  This  may  be 
performed  by  aspiration  with  a  trocar  and  cannula,  or  by  the 
more  radical  and  more  effective  measure  of  incision  over  the 
bulging  mass.  Chronic  abscesses,  especiallv  those  originating 
from  dysentery,  may  be  drained  by  incision  through  the  upper 
abdomen  or  by  the  transthoracic  route.  Drainage  by  cannula 
and  rubber  tube  is  recommended  b}"  some,  but  because  of 
the  movements  of  the  liver  this  method  has  been  deemed 
objectionable. 

Much  has  been  said  of  late  regarding  the  use  of  ipecac  in 
the  treatment  of  amebic  abscesses.  Ludlow^^  refers  to  his 
experience  at  the  research  department  of  the  Severance  Union 
Medical  College,  Seoul,  Korea,  regarding  the  emetin  treat- 
ment of  tropical  abscess  of  the  liver,  as  follows : 

"In  1913  emetin  was  used  in  three  out  of  four  cases,  and  was 
given  twice  a  day  in  doses  of  ^4  grain  each  for  a  week  fol- 
lowing operation.  Except  in  one  case  where  ameba  were 
found  in  the  feces,  it  seemed  to  be  of  no  special  importance  in 
hastening  the  recover}'.  In  1914  emetin  was  used  in  four  out 
of  six  patients.  This  time  it  was  given  in  ^-grain  doses  twice 
a  dav  for  six  days.  During  this  period  there  was  no  marked 
improvement  which  could  be  attributed  to  emetin,  but  it  was 
continued  because  others  had  reported  good  results.  In  1915 
it  was  given  in  1 -grain  doses  once  daily  for  a  week.  During 
this  time  emetin  was  used  for  periods  longer  than  a  week,  but 
no  rapid  progress  was  noted  after  its  use."  It  is  believed  in 
the  experience  of  Dr.  Ludlow  that  drainage  of  the  abscess 
gives  better  results  than  when  emetin  is  used  alone. 

Abscess  of  tuberculous  origin  always  should  be  evacuated, 
and  the  usual  treatment  of  tuberculosis  instituted. 

ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

This  disease  is  an  acute  destructive  process  of  the  liver 
cells  manifested  by  jaundice,  hemorrhage,  and  various  nerv- 
ous phenomena.    The  liver  is  much  reduced  in  size  and  weight, 


FATTY  DEGENERATION  OF  THE  LIVER.  909 

soft  and  friable,  and  of  a  mahogany-brown  or  grayish-yellow 
color.  Its  cut  surface  presents  areas  of  yellow  atrophy  inter- 
mingled with  red  pigmented  areas  of  congestion.  There  is  a 
distinct  degeneration  of  the  liver  cells,  which  are  replaced  by 
fat  globules,  cellular  debris,  and  blood  pigment.  The  disease 
is  caused  by  a  toxic  agent  or  agents  having  a  special  affinity 
for  the  liver  and  causing  a  precipitation  of  fat.  The  exact 
etiology  is  uncertain,  but  among  the  predisposing  causes  are 
acute  alcoholism,  puerperal  fever,  typhoid  fever,  septic  infec- 
tions, malarial  fever,  and  syphilis.  The  disease  begins  with 
severe  headache,  backache,  nausea,  vomiting,  and  fever,  and 
later  on  deep  jaundice  supervenes,  together  with  nervous 
symptoms — delirium,  convulsions,  stupor,  and  coma.  The 
vomiting  becomes  severe  and  bloody,  and  hemorrhage  may 
occur  in  any  part  of  the  intestinal  tract,  in  the  lungs  and  in 
the  skin,  causing  extreme  prostration  and  shock.  The  urine  is 
highly  colored  and  contains  bile  pigments,  albumin,  and  casts. 
There  is  tenderness  over  the  area  of  the  liver,  exaggerated  on 
pressure.  The  hepatic  outline  indicates  that  this  organ  is  con- 
siderably diminished  in  size. 

The  treatment  of  acute  yellow  atrophy  of  the  liver  is  symp- 
tomatic. Vomiting  should  be  controlled  by  gastric  lavage,  by 
the  use  of  cracked  ice,  and  by  an  ice-pack  applied  to  the  ab- 
domen. The  elimination  of  toxic  products  should  be  at- 
tempted by  colonic  irrigation.  Stimulants  are  called  for,  and 
should  be  administered  freely.  No  special  remedy  is  known 
for  the  disease,  which  is  virtually  always  fatal. 

FATTY  DEGENERATION  OF  THE  LIVER. 

This  may  be  considered  a  mild  type  of  yellow  atrophy,  its 
pathologic  changes  being  similar  but  on  a  smaller  scale,  and 
its  symptoms  less  severe.  The  liver  cells  are  disintegrated 
and  replaced  by  fat  globules,  which  tend  to  obliterate  the  in- 
terlobular framework  of  the  liver,  causing  it  to  become  frial)le 
and  soft,  shrunken  and  smaller  than  normal.  Granular  debris, 
cholesterin  and  tyrosin  crs^stals  intermingle  with  the  newly 
formed  fatty  tissue.  The  disease  occurs  among  alcoholics, 
workers  in  phosphorus,  arsenic,  and  other  poisonous  products, 
cachetic  diseases  such  as  cancer,  tuberculosis,  pernicious 
anemia,  and  in  acute  infectious  fevers. 


910  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

The  syniptODis  indicative  of  this  process  may  not  be  mani- 
fest at  the  onset  of  the  disease.  Later,  however,  there  is  pain 
over  the  liver,  jaundice,  and  gastro-intestinal  disorders.  Tlie 
severe  type  resembles  very  much  acute  yellow  atrophy. 

TREATMENT. 

Persons  employed  among  poisons  should  be  protected  from 
their  effects  by  routine  systematic  supervision  of  their  health. 
Employers  can  do  much  by  rendering-  the  workshop  healthful 
bv  free  ventilation  and  b}'  rendering  poisonous  materials  less 
harmful  through  a  system  of  exhausts.  Workers  should  be 
required  to  bathe  at  least  once  daily,  to  wash  the  hands  be- 
fore eating,  to  change  their  underclothing  at  frequent  inter- 
vals, and  to  give  special  attention  to  their  personal  habits. 
A  cathartic  taken  once  weeklv  is  very  valuable  in  keeping  the 
intestinal  tract  free  of  poisonous  substances.  AMien  the  dis- 
ease develops,  however,  the  diet  should  be  well  regulated  with 
a  view  of  lessening  the  burden  of  the  liver  by  eliminating  fats 
and  sweets.  Effervescent  phosphate  of  soda  should  be  given 
once  daily.  The  patient  should  spend  as  much  time  in  the 
open  as  possible,  and  a  tonic  administered  where  the  anemia 
indicates  its  use. 

FATTY  INFILTRATION  OF  THE  LIVER. 

This  disease  is  characterized  by  a  deposit  of  fat  in  the  liver 
cells,  occurring  either  locally  or  generally  throughout  the  liver. 
The  organ  is  enlarged,  sometimes  assuming  immense  propor- 
tions, being  many  times  its  usual  weight.  The  preponderance 
of  fat  gives  the  liver  a  light  yellow  color,  its  sharp  borders  be- 
come rounded,  and  the  hepatic  tissue  becomes  soft.  Its  cut 
surface  presents  a  shiny  appearance.  When  examined  micro- 
scopically, the  protoplasm  of  the  liver  cells  seems  to  be  pushed 
aside  by  the  invading  fat  droplets. 

The  symptoms  are  those  usually  found  in  general  obesity, 
except  when  it  occurs  in  the  course  of  wasting  diseases  such 
as  cancer,  syphilis,  tuberculosis,  chronic  malaria,  when  the 
predominating  symptoms  of  these  respective  diseases  mask 
those  produced  bv  the  liver  infiltration.  Extensive  deposit  of 
fat  in  the  liver  embarrasses  the  circulation  and  respiration. 


AMYLOID  DISEASE  OF  THE  LIVER.  911 

There  is  dyspnea,  arrhythmia,  irregular,  feeble  pulse,  and  gen- 
eral excitability.  The  liver  is  enlarged,  sometimes  reaching  as 
low  as  the  umbilicus. 

The  treatment  of  this  condition  calls  for  abstinence  from 
sweets  and  starches.  Cereals,  potatoes,  candies,  jellies,  and 
other  sweetened  deserts  should  be  rigidly  avoided.  Rye  and 
bran  bread  should  replace  wheat.  Bacon,  oil  dressing,  fried 
and  fatty  foods  should  be  stricken  from  the  diet.  A  small  pro- 
portion of  butter,  however,  is  permissible.  Boiled  meats,  veal, 
chicken  and  fish  (except  shad),  fresh  vegetables,  and  fruits  are 
permissible.  Alcohol,  of  course,  is  prohibited.  A  diet  of  milk, 
buttermilk,  and  skim  milk,  taken  alternately  for  several  weeks, 
may  prove  of  great  value.  Regulated  and  systematized  baths, 
taken  under  supervision,  may  accelerate  the  reduction  of  the 
fat  deposit  in  the  liver.  Exercises  both  indoor  and  outdoor 
assist  in  reducing  accumulated  fat.  The  bowels  should  be  kept 
free  by  taking  1  teaspoonful  (3.75  Cms.)  of  efifervescent  phos- 
phate of  soda  in  a  glass  of  hot  water  every  morning  before 
breakfast. 

When  fatty  infiltration  occurs  in  the  course  of  cachectic 
diseases,  fats  and  sugars  should  be  reduced  in  quantity. 

AMYLOID  DISEASE  OF  THE  LIVER. 

This  is  a  destructive  disease  of  the  liver  in  which  the  proto- 
plasm of  the  liver  cells  is  replaced  by  a  lardaceous  waxy  sub- 
stance— a  coagulated  albumin  called  amyloid.  It  may  occur 
in  the  liver  alone  or  as  a  part  of  generalized  amyloid  disease. 
It  is  found  in  persons  suffering  from  tuberculosis,  syphilis, 
cancer,  and  chronic  bone  infections.  The  liver  is  firm  to  the 
touch,  enlarged,  sometimes  quite  considerably,  and  on  section 
presents  a  grayish-brown,  shiny  appearance. 

The  symptoms  are  those  of  anemia — sallow  complexion, 
loss  of  weight,  and  gastro-intestinal  disturbance.  Diarrhea 
with  mucous  discharge  may  be  present.  The  urine  is  highly 
colored,  containing  albumin  and  waxy  casts;  an  enlarged 
spleen  is  usually  associated. 

The  treatment  should  be  aimed  at  the  causative  ag'ents — 
tuberculosis,  syphilis,  cancer,  and  bone  infections.  Tonics, 
fresh,  wholesome  food,  fresh  air,  and  sunshine  are  the  com- 


912  DISEASES    OF    THE  ■  DIGESTIVE    SYSTEM. 

monplace  remedies.     Syphilis  calls  for  special  treatment,  while 
chronic  bone  infections  demand  appropriate  surgical  measures. 

SYPHILIS  OF  THE  LIVER. 

The  liver  is  quite  often  the  seat  of  syphilitic  infection, 
either  congenital  or  acquired.  The  former  is  most  often  found 
among  infants,  and  is  characterized  by  diffuse  infiltration  of 
connective  tissue  and  round  cells.  The  liver  is  grayish-yellow, 
larger  than  normal,  and  resists  the  cutting  knife.  The  con- 
nective tissue  infiltration  may  be  localized  in  nodular  masses, 
which  later  undergo  contraction,  presenting  miliary  gummata. 

Acquired  syphilis  of  the  liver  makes  itself  evident  some 
time  after  the  original  lesion — a  developmental  period  ranging 
from  three  to  twenty  years.  The  organ  in  this  instance  shows 
areas  of  necrosis  surrounded  by  abundant  round-cell  infiltra- 
tion and  connective  tissue,  comprising  the  so-called  gummata. 
These  either  break  down  through  solution  of  tissue  and  are 
replaced  by  scars,  or  they  undergo  a  fibroid  change  forming 
hard  nodular  masses.  AVhen  liquefaction  of  the  gummata 
takes  place,  the  resulting  scars  dent  the  surface  of  the  liver, 
which,  altered  in  shape  and  size,  becomes  surrounded  by  dense 
and  firm  capsule.  In  some  instances,  fibrous  protuberances 
may  be  seen  and  felt  under  the  thickened  capsule.  The  liver 
at  first  is  enlarged,  but  as  fibrosis  proceeds  it  is  contracted 
and  diminished  in  size.  The  cut  surface  shows  a  preponder- 
ance of  fibrous  tissue ;  the  blood-vessels  are  thickened  and 
hardened.  Miliary  fibrous  masses  may  also  be  seen  in  con- 
genital syphilis. 

Syphilis  of  the  liver  in  infants  is  usually  associated  Avith 
other  signs  of  a  congenital  infection.  The  liver  is  quite  en- 
larged. In  adults,  however,  there  may  be  few  or  no  symptoms 
at  the  onset.  As  the  connective  tissue  changes  take  place 
there  are  signs  of  portal  obstruction  and  sometimes  jaundice. 
The  patient  may  complain  of  pain  over  the  liver,  which  is  ex- 
aggerated on  pressure.  Palpation  of  the  liver  reveals  nodular 
protuberances  on  its  surface,  and  on  percussion  the  organ  is 
found  to  be  enlarged.  In  the  later  stage,  however,  the  liver 
is  contracted  at  its  lower  edge  and  cannot  be  palpated.  When 
ascites  is  present,  the  usual  signs  of  fluid  in  the  abdomen 
prevail. 


TUMORS  OV  THE  LIVER.  913 

The  treatment  of  syphilis  of  the  liver  is  that  of  the  tertiary 
stage  of  the  disease.  lodids  are  given  to  the  stage  of  toler- 
ance in  conjunction  with  mercury.  Active  infection  as  mani- 
fested by  blood  test  indicates  the  need  for  intravenous  injec- 
tion of  salvarsan  (arsphenamin),  repeated  as  the  individual 
case  requires.  When  the  disease  has  so  far  advanced  as  to 
cause  distinct  fibrosis  of  the  liver,  very  little  can  be  done  by 
way  of  medication.  Congenital  syphilis  calls  for  inunctions 
by  mercury  and  mixed  treatment  internally.  (See  Syphilis, 
vol.  i,  p.  76.) 

TUBERCULOSIS  OF  THE  LIVER. 

Tuberculosis  of  the  liver  may  be  a  part  of  a  general  infec- 
tion, and  present  itself  in  the  form  of  miliary  tubercles  scat- 
tered throughout  the  organ,  as  solitary  tubercles  or  abscesses, 
as  a  tuberculosis  cholangitis,  or  as  a  tubercular  cirrhosis.  The 
pathologic  findings  are  self-explanatory  from  the  respective 
names.  The  treatment  of  tuberculosis  of  the  liver  is  the  same 
as  tuberculosis  elsewhere,  and  is  therefore  not  discussed  here. 
(See  vol.  i,  p.  68,  et  seq.) 

TUMORS  OF  THE  LIVER. 

Among  the  tumors  affecting  the  liver  are  cancer,  sarcoma, 
angioma,  adenoma,  and  cysts.  Cancer  is  most  common  after 
the  age  of  35,  and  may  be  primary  or  secondary.  The  latter 
is  more  frequent  among  women,  being  secondary  to  carcinoma 
of  the  uterus  and  mammary  glands.  They  may  be  of  hard  or 
soft  type,  resembling  scirrhus  or  medullary  carcinoma  in 
other  parts  of  the  body.  The  etiology  and  general  symptoms 
are  those  of  cancer  elsewhere. 

Sarcoma  may  invade  the  liver  in  its  various  forms,  either 
small  round  cell,  large  round  cell,  or  melanotic  variety.  The 
last-named  may  follow  sarcoma  of  the  orbit. 

Tumors  of  the  liver  are  manifested  by  pressure-symptoms 
which  interfere  with  the  portal  or  biliary  circulation  and  by 
pressure  upon  the  inferior  vena  cava  and  adjacent  viscera. 
When  the  tumor  is  secondary  to  growths  in  other  organs,  the 
symptoms  referable  to  these  original  seats  of  origin  are  asso- 

58 


914  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

ciated.  Jaundice,  pain,  ascites,  fever,  and  cachexia  are  the 
dominating  signs  of  malignant  growths  in  the  advanced 
stag"es.  Symptoms  of  toxemia  precede  a  fatal  termination. 
The  liver  is  enlarged  and  nodular.  The  treatment,  of  course, 
is  symptomatic. 

Cystic  conditions  of  the  liver  may  be  treated  by  appropriate 
surgical  measures  of  drainage.  The  .i--ray  is  valuable  not  only 
in  diagnosis,  but  maA'  also  be  of  assistance  in  conjunction  with 
other  measures  in  the  treatment  of  neoplasms. 


DISEASES  OF  THE  PANCREAS. 

GENERAL  CONSIDERATIONS. 

In  considering  diseases  of  the  pancreas,  it  becomes  neces- 
sary to  study  the  urine  and  the  feces,  in  order  to  ascertain  if 
the  pancreas  itself  is  implicated,  or  if  the  pathologic  process  is 
outside  of  that  organ.  So  much  confusion  has  in  the  past 
arisen  in  the  study  of  some  of  the  more  salient  facts  bearing 
upon  this  subject,  that  the  following  epitome  has  been  gleaned 
from  the  many  investigations  of  Prof.  J.  C.  Attix,  of 
Philadelphia. 

The  secretions  of  the  pancreas  carry  on  an  enzymotic 
action  on  carbohydrates  and  fats.  If  the  pancreas  is  at  fault, 
the  feces  should  be  normal  in  color  (because  of  the  normal 
presence  of  indol.  skatol,  etc.,  coming  from  the  liver).  If 
these  products  are  not  present,  one  would  suspect  a  disease 
of  the  liver,  bile-ducts,  or  gall-bladder,  rather  than  the  pan- 
creas, or  both  may  be  diseased.  If  the  inflammation  of  the  pan- 
creas is  of  such  an  extent  as  to  interfere  with  its  functions, 
sugar  ma}^  be  found  in  the  urine,  and  undigested  and  unemul- 
sified  fats  in  the  feces,  although  the  latter  would  still  have  the 
normal  color  if  the  biliar\'  secretions  have  free  entrance  to  the 
intestines. 

Both  bile  and  steapsin  emulsify  fats.  If  the  inflammation 
were  sufidciently  marked  to  affect  the  pancreatic  duct  and  com- 
mon bile-duct,  then  there  would  not  be  an  emulsification  of 
fats  by  either  bile  or  pancreatic  secretion,  and  the  feces  would 
be  of  a  lig-ht  color.  Absence  of  emulsified  fats  and  clay- 
colored  stools  are  more  likely  to  be  connected  with  a  liver 


GENERAL  CONSIDERATIONS.  915 

affection.  If  the  feces  are  normal  in  color,  with  the  presence 
of  unemulsified  fats,  and  also  the  presence  of  sugar  in  the 
urine,  it  is  more  likely  that  the  pancreas  is  at  fault.  In  either 
case  it  mig'ht  be  the  ducts  and  not  the  organs  themselves,  as 
in  the  case  of  a  biliary  or  pancreatic  calculus. 

The  islands  of  Langerhans  are  credited  with  elaborating  a 
specific  enzyme  and  also  an  internal  secretion  which  convert 
sugar  and  maltose  into  an  assimilable  form.  Amylopsin  con- 
verts sugars  and  starches  into  monosaccharides,  and  these  are 
taken  up  by  the  portal  circulation  to  the  liver,  where  they  are 
again  modified  into  polysaccharides,  glycogen,  and  similar 
products,  so  that  when  finally  delivered  to  the  tissues  they 
are  readily  converted  into  heat,  energy,  support  general  metab- 
olism, and  are  in  a  readily  combustible  form,  the  CgHioO,; 
being  converted  into  CO2  and  H2O. 

In  either  of  these  cases,  where  acute  pancreatitis  with  in- 
flammation is  sufficient  to  prevent  the  entrance  of  the  pan- 
creatic secretion  into  the  intestines,  sugar  may  be  found  in  the 
urine,  not  from  lack  of  pancreatic  secretion,  but  from  the  fact 
that  the  inflammatory  process  prevents  its  mingling  with  the 
substances  on  which  it  ordinarily  exerts  its  enzymotic  action. 

The  Cammidge  reaction,  which  some  years  since  gave 
promise  of  being-  an  invaluable  aid  in  the  differentiation  of 
pancreatic  diabetes  from  diabetes  of  other  origin,  has  proved 
itself  fallacious.  For  the  muscle  juices,  pancreatic  secretion, 
and  probably  the  internal  secretions  of  the  islands  of  Langer- 
hans, the  adrenals  and  the  pancreas  all  play  a  part  in  the 
breaking  up  of  the  monosaccharides  by  converting  them  into 
carbon  dioxid  and  water,  with  the  development  of  heat  and 
energy,  without  leaving  behind  an  excess  of  sugar  floating 
free  in  the  blood. 

Of  course,  many  of  the  statements  and  deductions  formu- 
lated by  medical  men  and  widely  published  are  relative  and 
largely  in  the  abstract ;  otherwise,  medicine  would  lack  the 
essentials  of  being  a  scientific  study. 

The  foreging  facts,  therefore,  may  have,  in  certain  in- 
stances, their  limitations,  but  as  broad,  general  statements  in 
physiologic  chemistn^  they  represent  the  present  state  of  our 
knowledge  in  this  difficult  field  of  endeavor,  and  are  herein 
incorporated  in  the  text,  in  the  hope  of  clarifying  a  number 


916  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

of  medical  entities,  that  by  their  obscure  symptomatology  too 
often  baffle  the  physician  in  his  diagnosis. 


PANCREATIC  HEMORRHAGE. 

Slight  hemorrhages  into  the  pancreas  are  of  little  clinical 
interest.  They  may  be  secondary  to  excessive  chronic  passive 
congestion,  to  acute  infectious  diseases,  or  the  hemorrhagic 
diathesis.  ]\lost  cases  occur  after  the  fortieth  year  of  life,  and 
apparently  at  times  without  cause.  Factors  favoring  pan- 
creatic hemorrhage  are  :  traumatism,  arteriosclerosis,  alcoholism, 
and  causes  most  likely  acting  in  bringing  about  a  cerebral 
apoplexy. 

The  only  constant  symptoms  are  sudden  agonizing  pains, 
followed  by  collapse.  The  pain  in  certain  cases  is  only  trivial. 
The  severe  pain  complained  of  is  usually  referred  to  the  epi- 
gastrium; at  other  times  it  is  not  sharply  defined.  Severe 
forms  of  pancreatic  hemorrhage  usually  prove  fatal  within 
twenty-four  hours,  death  being  caused  by  reflex  paralysis  of 
the  heart,  due  to  some  coincident  vascular  affection  or  to  pres- 
sure upon  the  solar  plexus  and  semilunar  ganglion. 

Treatment.  This  consists  in  the  relief  of  pain  and  in  meet- 
ing the  collapsed  condition.  ]\Iorphin  should  be  given  to  re- 
lieve the  pain,  and  the  collapse  should  be  treated  in  the  usual 
manner,  by  the  application  of  heat,  alcoholic  stimulation,  by 
the  hypodermic  injection  of  atropin  and  str}^chnin,  and  by  the 
use  of  digitalis.  Since  death  results  from  pressure-symptoms 
upon  important  nerve  structures  as  previously  mentioned,  it  is 
suggested  that  free  incisions  around  the  pancreas  might  re- 
lieve this  condition,  and  thus  be  the  means  of  saving  the 
patient's  life. 

ACUTE  PANCREATITIS. 

This  is  a  lesion  of  the  pancreas  in  which  the  hemorrhagic 
process  is  in  association  with  an  active  inflammation.  ]\Iost 
of  the  cases  reported  have  occurred  in  males  past  50  years  of 
age.  It  is  more  prone  to  attack  the  obese  than  those  of  a 
"lean  habit."  An  especial  predisposition  to  the  disease  seems 
to  be  the  effects  of  a  gastroduodenal  catarrh,  gall-stones,  alco- 
holism, and  traumatism.    Diseases  of  the  gall-bladder  are  not 


Acute  pancreatitis.  ^17 

infrequently  followed  by  acute  pancreatitis,  and  Flexner, 
among-  others,  realizing  the  dominant  [)art  played  by  bacteria, 
in  cholelithiasis  and  kindred  affections  of  the  gall-duct  and 
bladder,  produced  experimental  inflammations  of  the  pancreas 
by  the  injection  of  various  bacteria. 

The  symptoms  of  the  disease  arise  suddenly,  and  with  great 
violence.  There  is  deep-seated,  agonizing  pain  in  the  epigas- 
tric region,  or  between  the  tip  of  the  xiphoid  and  the  navel. 
This  is  soon  followed  by  severe  and  continuous  vomiting. 
Fever  is  usually  slight  or  may  be  absent,  although  in  some 
cases  the  febrile  rise' may  register  as  high  as  104°  F.  (40°  C.)- 
Among  other  more  or  less  common  symptoms  are  dyspnea, 
rapid,  feeble  pulse,  and  constipation,  although  in  some  cases 
diarrhea  may  be  present,  with  watery  stools  containing  free 
fat.  Tympanites  occurs  in  a  majority  of  the  cases,  and  hic- 
coug'h  and  albuminuria  may  be  noted.  The  intense  pain  and 
profound  collapse  are  either  dependent  upon  a  circumscribed 
peritonitis  or  to  pressure-symptoms  upon  the  solar  plexus. 
The  diagnosis  of  acute  pancreatitis  is  best  made  by  exclu- 
sion. Surely,  the  above  narration  might  apply  equally  well 
as  part  of  the  symptom-complex  of  many  aftections.  But,  in 
brief,  Ziehen  a  previously  healthy  person  is  suddenly  seized  ivith 
excruciating  pain  in  the  upper  abdomen,  zvith  nausea  and  vomiting 
and  profound  collapse,  this  disease  should  akvays  be  suspected. 

The  afifections  from  which  it  can  be  quite  clearly  defined, 
but  which  it  would  be  irrelevant  to  digress  upon  in  this  brief 
review,  are:  intestinal  obstruction,  biliary  colic,  perforating 
gastric  or  duodenal  ulcer,  and  the  action  of  corrosive  poisons. 

Treatment.  This  is  merely  palliative  and  symptomatic.  The 
agonizing  pain  demands  full  doses  of  morphin,  and  the  symp- 
toms of  collapse  should  be  treated  by  external  heat,  the  injec- 
tion of  warm  saline  solutions,  and  hypodermics  of  atropin, 
strychnin,  and  difTusable  stimulants.  The  diet  should  be  rela- 
tively free  from  fat,  and  it  has  been  recommended  that  por- 
tions of  pancreas  be  added  to  the  food  to  be  taken  by  the 
patient,  in  the  hope  that  the  food  is  in  this  way  brought  more 
or  less  in  contact  with  the  pancreatic  juices,  which  are  so 
essential  for  normal  digestion.  Diastase  has  also  proven  its 
value,  when  administered  immediate^  after  food  is  taken ;  to 
some  extent  it  supplants  the  pancreatic  juices.     Later,  in  the 


918  DISEASES   OF   THE   DIGESTIVE   SYSTEM. 

course  of  the  disease,  a  supporting  nutritious  diet  is  demanded, 
with  the  administration  of  tonics  and  stimulants. 


CHRONIC  PANCREATITIS. 

This  may  follow  attacks  of  the  acute  form,  but  more  often, 
especially  in  alcoholics,  it  is  the  result  of  a  persistent  or 
recurring  gastroduodenal  catarrh,  affecting-  the  pancreatic 
'duct. 

Conditions  g"iving-  rise  to  occlusion  of  the  common  or  pan- 
creatic ducts,  or  both,  as  evidenced  in  cases  of  gall-stones,  pan- 
creatic calculi,  and  tumors,  occasion  a  chronic  indurative 
change  in  the  organ.  Ligation  of  the  duct  of  Wirsung  in  the 
lower  animals  is  followed  by  an  increase  in  the  fibrous  struc- 
tures of  the  gland ;  and  in  his  memorable  labors  in  the  investi- 
gation of  pancreatic  diseases  Fitz  declared  that  "fibrous 
thickening  of  the  pancreas  is  even  associated  with  ulcer  of 
the  stomach  or  suprarenal  capsule,  aneurysm  of  the  aorta  or 
celiac  axis,  or  with  disease  of  the  spine." 

The  symptoms  are  scarcely  indicative  of  chronic  pancrea- 
titis, the  patient  giving  the  history  of  a  chronic  gastric 
catarrh  of  long  standing,  wnth  frequent  attacks  of  diarrhea. 
Later  there  is  epigastric  pain,  slight  rise  of  temperature,  and 
great  anxiet}^  As  a  result  of  pressure  there  may  be  some 
ascites  and,  possibly,  jaundice.  There  is  usually  progressive 
loss  of  flesh  and  strength.  The  detection  of  free  fat  in  the 
dejections  without  jaundice  and  the  occurrence  of  glycosuria 
and  lipuria  are  of  great  diagnostic  value.  The  recognition  of 
the  disease  is  extremely  difficult;  it  should,  however,  be  sus- 
pected in  patients  who  give  a  history  of  long-continued 
chronic  gastric  catarrh  with  frequent  attacks  of  diarrhea,  loss 
of  flesh  and  strength,  and  the  detection  of  free  fat  in  the  de- 
jections. 

The  presence  of  glycosuria  is  of  great  importance  in 
deciding  the  true  nature  of  the  afifection.  It  is  safe  to 
infer  that  the  secreting  structure  of  the  pancreas  is  destroyed, 
or  that  there  is  occlusion  of  the  duct,  if,  upon  the  adminis- 
tration of  salol.  its  decomposition  is  not  efifected  in  the  in- 
testinal canal,  and  the  presence  of  carbolic  acid  fails  to  ap' 
pear  in  the  urine. 


PANCREATIC  CALCULI.  919 

TREATMENT. 

The  main  object  of  treatment  in  chronic  pancreatitis  is  the 
proper  regulation  of  the  patient's  diet.  All  food  requiring 
pancreatic  juice  for  its  digestion  should  be  reduced  to  a  mini- 
mum; these  include  the  fats  and  the  starches.  When  the 
latter  are  to  form  part  of  the  dietary,  they  should  be  fol- 
lowed fifteen  or  twenty  minutes  after  the  meal  by  prepara- 
tions of  pancreatin  and  soda.  Malt  diastase  combined  with 
alkalies  should  also  be  tried.  The  use  of  carbonated  waters 
are  to  be  recommended,  for  Becher  has  found  that  they  in- 
crease the  pancreatic  digestion  and  its  digestive  power  in 
dogs.    Other  symptoms  must  be  treated  as  they  arise. 

PANCREATIC  CALCULI. 

These  concretions  are  in  all  probability  produced  by  a 
catarrhal  inflammation  and  the  retention  of  secretions  in  the 
duct  of  Wirsung.  Other  causes  responsible  for  this  sort  of 
stone  are  anomalies  of  the  pancreatic  secretion  and  the  pres- 
ence of  cysts  or  some  other  factor  that  causes  occlusion  of 
the  pancreatic  duct. 

The  first  symptom  suggestive  of  a  calculus  is  pain,  without 
special  tenderness,  and  due  probably  to  the  displacement  of 
the  calculus.  It  strongly  simulates  biliary  colic,  and  occasion- 
ally jaundice  is  present.  The  radiation  of  pain  along  the  lower 
left  costal  border  rather  than  to  the  right  side,  and  at  times 
the  detection  of  fat  in  the  stools  or  of  glycosuria,  are  great 
aids  in  the  diagnosis.  There  is  progressive  loss  of  flesh  and 
strength,  and  stools  often  contain  fat  acids,  muscular  fibers, 
and  at  times  pancreatic  concretions.  Occasional  or  perma- 
nent glycosuria  may  be  present. 

TREATMENT. 

For  the  relief  of  the  intense  pain  that  accompanies  the 
passage  of  a  calculus  morphin  should  be  freely  administered 
subcutaneously,  and,  if  necessary,  ether  or  chloroform  may  be 
given.  The  application  of  heat  to  the  abdominal  wall  may 
also  be  of  considerable  service.  The  treatment  of  the  ultimate 
results  of  pancreatic  calculi  is  that  of  chronic  pancreatitis 
{q.v.).    After  the  calculus  has  lodged  in  the  excretor}^  duct  of 


920  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

the  organ,  medical  treatment  is,  of  course,  unavailing,  but  it  is 
highly  probable  that  recovery  in  these  instances  would  follow 
intelligent  surgical  intervention.  The  possibility  of  the  suc- 
cessful removal  of  a  calculus  before  permanent  alterations  in 
the  pancreas  have  taken  place  should  never  be  lost  sight  of. 

PANCREATIC  CYSTS 

These  are  most  common  between  the  ages  of  20  and  30, 
and  occasionally  follow  traumatism.  They  may  occur  in  chil- 
dren, and  by  some  investigators  they  are  believed  to  be  con- 
genital. The  commonest  cause  is  obstruction  of  the  pan- 
creatic duct,  and  this  may  be  due  to  inflammation  of  its  wall 
or  to  inflammation  of  the  pancreas  in  the  immediate  vicinity  of 
the  duct,  to  the  impaction  of  calculi,  and  pressure  of  tumors. 
In  a  remarkable  case  reported  by  Durante,  a  cyst  resulted  from 
the  occlusion  of  the  duct  of  Wirsung  by  a  round  worm.  Para- 
sitic cysts  are  likewise  sometimes  the  cause.  It  is  believed 
by  some  that  many  cases  diagnosed  as  pancreatic  cysts  are 
really  inflammatory  conditions  of  the  tissues  surrounding  the 
organ,  with  accumulations  of  inflammatory  products. 

Pancreatic  secretion  is  absent,  and  pressure-symptoms  are 
always  characteristic  of  the  presence  of  a  cyst.  There  may  be 
absence  of  pain,  or  when  present  it  may  occur  in  severe  colicky 
paroxysms,  and  be  referred  to  the  left  epigastrium,  left  hypo- 
chondrium,  the  left  shoulder,  and,  perhaps,  the  left  half  of  the 
face.  There  is  frequent  vomiting,  constipation,  or  diarrhea, 
and  the  patient  complains  of  a  feeling  of  fullness  in  the  epi- 
gastrium, which  may  be  exquisitely  tender.  Emaciation  is 
frequent,  albumin,  sugar  and  often  blood  are  found  in  the 
urine.  On  physical  examination  the  cyst  is  smooth,  elastic, 
and  lobulated.  Its  growth  is  likely  to  be  slow,  frequently  re- 
maining small  and  stationarj^  for  a  long  period  of  time,  when, 
after  a  short  interval,  it  may  attain  a  very  large  size.  It  fre- 
quently transmits  aortic  pulsations.  It  is  dull  on  percussion 
where  tympanitic  structures  such  as  the  stomach  and  intes- 
tines are  not  superimposed. 

Auscultation  may  reveal  a  murmur  caused  by  compres- 
sion of  the  aorta.  As  the  cyst  increases  in  size,  pressure 
effects  bring  about  a  chain  of  symptoms  that  adds  much  suf- 


CARCINOMA  OF  THE  PANCREAS.  921 

fering  to  the  patient's  already  distressing  condition.  As  a  re- 
sult of  this  mechanical  disturbance,  atrophy  of  the  pancreas 
may  occur,  although  digestion  and  assimilation  are  not  inter- 
fered with.  Dyspnea,  ascites,  and  dropsy  of  the  lower  half 
of  the  body  are  all  likely  to  be  in  evidence.  If  the  gland  is 
completely  damaged,  or  if  the  duct  is  so  occluded  that  pan- 
creatic juice  cannot  be  discharged,  the  feces  may  contain  fat, 
and  glycosuria  may  be  present,  with  a  decreased  amount  of 
indican  in  the  urine.     Salivation  is  sometimes  noted. 

Treatment.  There  is  no  medical  treatment  of  pancreatic 
cysts.  When  producing  permanent  or  serious  discomfort, 
they  call  for  surgical  intervention.  The  prognosis  is  good 
under  ordinary  conditions,  unless  diabetes  coexists. 


CARCINOMA  OF  THE  PANCREAS. 

Benign  tumors  of  the  pancreas  are  rare,  and  of  no  clinical 
interest.  Carcinoma  of  the  pancreas  is  most  common  in  the 
male  sex  past  the  fortieth  year,  although  cases  have  been  re- 
ported in  the  newborn. 

Cancer  of  the  pancreas  may  exist  without  giving  rise  to 
symptoms,  which  when  present  are  referred  to  gastro-intes- 
tinal  disturbances.  The  patient  complains  of  a  stubborn 
dyspepsia,  progressive  loss  of  flesh  and  strength,  and  gnawing 
or  sometimes  sharp  epigastric  pain.  Nocturnal  paroxysms  of 
pain  are  frequent,  and  are  often  accompanied  with  symptoms 
of  collapse.  Constipation  or  diarrhea  may  prevail,  and  when 
vomiting  occurs  blood  or  free  fat  may  be  found  in  the 
ejected  matter  at  times.  Blood  may  be  passed  by  the  bowel, 
but  the  presence  of  fat  or  fat  acids  are  rarely  demonstrable ; 
the  stools  are  light  in  color,  and  when  diarrhea  is  not  present 
much  undigested  muscular  fiber  is  found  in  the  dejections. 
The  urine  may  be  increased  in  quantity,  and  sugar  and  albumin 
are  sometimes  present.  The  characteristic  feature  of  cancer 
of  the  pancreas  is  the  discovery  of  a  palpable  tumor  in  the 
region  of  the  gland.  It  is  deep-seated  in  the  middle  line  and 
above  the  navel.  It  is  very  slightly  movable,  and  varies 
greatly  in  contour,  shape  and  densiity,  and  usually  transmits 
the  pulsations  of  the  abdominal  aorta.     The  pressure-symp- 


922  DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

toms  are  identical  with  the  mechanical  disturbances  produced 
by  pancreatic  cysts  (v.s.). 

TREATMENT. 

The  symptoms  of  pancreatic  cancer  that  require  treatment 
are  pain  and  ascites.  The  pain  is  to  be  relieved  by  hypodermic 
injections  of  morphin,  and  the  ascites,  if  the  cause  of  much 
distress,  should  be  treated  by  abdominal  paracentesis.  (See 
p.  969.)  Of  course,  all  other  treatment  must  be  of  a  sympto- 
matic kind.  Diastase  and  portions  of  raw  pancreas  may  be 
g-iven  with  the  food,  with  the  hope  of  maintaining  the  diges- 
tive functions.  In  the  very  early  stages,  if  the  disease  is  recog- 
nized, an  operation  may  be  the  means  of  saving  life,  and, 
according  to  Koerte,  recovery  has  followed  in  several  cases 
the  extirpation  of  the  tumor,  but  as  a  rule  this  malignant  neo- 
plasm is  so  insidious  that  when  diagnosed  it  is  too  far 
advanced  for  an  operation.  [L.  L.] 

BIBLIOGRAPHY. 

1.  Daland,  J. :     Pa.  Med.  Jour.,  1917,  p.  771. 

2.  Freudenberger,  H. :     Lancet-Clinic,  1916. 

3.  Price,  W.  A. :    Jour.  Amer.  Med.  Assoc,  1917,  424. 

4.  Rhein,  M.  L. :    Loc.  cit.,  417. 

5.  Talbot,  E.  S. :    Loc.  cit.,  420. 

6.  Potter,  H.  E. :    Loc.  cit. 

7.  Anders,  J.  M. :     Principles  of  Medicine,  Phila.,  1909,  734. 

8.  Sippy,  B.  W. :  Therapeusis  of  Internal  Diseases,  Forcheimer,  1914, 
iii,  65. 

9.  MacCarty  and  Wilson :    x\m.  Jour.  Med.  Sc,  Dec,  1909. 

10.  Lyon :  A  Study  of  Gastric  Sediments  and  Their  Interpretation. 
Am.  Jour.  Med.  Sc,  Sept.,  1915. 

11.  Fenwick :    British  Med.  Jour.,  1909,  i,  1297. 

12.  Smithies  and  Ochsner :     Cancer  of  the  Stomach,  1916,  p.  440. 

13.  Whiting:    Annals  of  Surgery,  May,  1916. 

14.  Bolton  :    Ulcer  of  the  Stomach,  1913,  p.  315. 

15.  Musser  and  Kelly  :    Practical  Treatment,  iii,  348. 

16.  Lockwood :     Diseases  of  the  Stomach,  1913,  p.  183. 

17.  Loc.  cit.,  176. 

18.  Smithies  and  Ochsner :     Cancer  of  the  Stomach,  1916. 

19.  Fenwick :     Cancer  and  Other  Tumors  of  the  Stomach,  Phila.,  1903. 

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21.  Hoffman:  Trans.  A.  Gynec.  Soc,  1913;  Surg.  Gynec.  Obst.,  1914, 
p.  726. 


BICIJOCKAIMI Y.  923 

22.  Febiger :     Berl.  kliii.  Wochnschr.,  Feb.  17,  1913,  p.  289.    ' 

23.  Taschenbuch  der  Magcn  unci  Darm  Krankeitcn,  1912. 

24.  Lyon  :     Study  of  Gastric  Sediments  and  Their  Interpretation.     Am. 
Jour.  Med.  Sc,  1915,  p.  402. 

25.  Fuld  and  Levinson :     Biochem.  Ztschrft.,  Berl.,  1907,  Bd.  vi,  Hft.  5 
and  6,  p.  473.  ' 

26.  Schryver  and  Singer:     Quarterly  Jour.  Med.,  London,  Oct.,   1912, 
p.  71. 

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28.  Neubauer  and  Fisher:    Deutsch.  Arch.  f.  klin.  Med.,  1909,  xciii,  499. 

29.  Weinstein  :    Jour.  Am.  Med.  Assoc,  1910,  Iv,  1085. 

30.  Gossett :    La  Presse  Med.,  Mar.  16,  1912. 

31.  Smithies  and  Ochsner :     Cancer  of  the  Stomach,  1916. 

32.  Fenwick :     Cancer  and  Other  Tumors  of  the  Stomach,  Phila.,  1903. 

33.  Lockwood :    Diseases  of  the  Stomach,  1913,  p.  277. 

34.  Brooks :     Med.  News,  May  14,  1898. 

35.  Salomon :    Trans.  Path.  Soc,  London,  1914,  Iv. 

36.  Coley:    Annals  of  Surgery,  Sept.,  1891. 

37.  Chiari:    Festschrift  fitr  Rudolph  Virchow,  1891,  ii,  297. 

38.  Morgan :    Am.  Jour.  Med.  Sc,  Mar.,  1915,  cxlix.  No.  3,  392. 

39.  Lyon  and  Eiman :     Am.  Jour.  Med.  Sc,  Dec,  1914,  No.  6,  cxlviii, 
885. 

40.  Gradwohl :    Medical  Fortnightly,  Oct.  26,  1914. 

41.  Lyon  and  Eiman  :    Ibid. 

42.  Bassler :     Diseases  of  the  Stomach,  and  Upper  Alimentary  Tract,  p. 
679.    Lockwood :    Diseases  of  the  Stomach,  p.  298. 

43.  Mohler  and  Funk :    Am.  Jour.  Med.  Sc,  Sept.,  1916,  No.  3,  clii,  355. 

44.  Riviere  and  Morland :     Tuberculin  Treatment,  Oxford  Med.  Pub. 

45.  Holt:    Jour.  Am.  Med.  Assoc,  1917,  Ixviii,  1517. 

46.  Koplik :    Am.  Jour.  Med.  Sc,  1908. 

47.  Plummer :      Cardiospasm.      St.  Mary's  Hospital,    Rochester,   Minn., 
Collected  Papers,  1911,  i,  33-49. 

48.  Abrams'  Spondylotherapy,  Philopolis  Press,  San  Francisco. 

49.  Abrams  and  Jarvis :     Arch,  of  Diagnosis,  1912,  329. 

50.  Lyon  medicale,  1885.     Revue  de  Medicine,  1887,  p.  75.     Enteroptose 
et  Neurasthenic,  Soc.  Med.,  des  Hopitaux,  Paris,  1886. 

51.  Vettmann,   Henry   Wald. :     Forcheimer's   Therapeutics   of   Internal 
Diseases — Billings,  1917,  iii,  p.  272. 

52.  Mayo,  Wm.  J.:    Jour.  Am.  Med.  Assn.,  May  11,  1918,  p.  1361. 

53.  Ludlow,  A.  I. :    China  Medical  Journal,  May,  1917. 


Diseases  of  the  Peritoneum 

BY 

WILMER  KRUSEN,  M.D.,  LLD.,  F.A.C.S., 

Professor  of  Gynecology,  Temple  University  of  Philadelphia,  Depart- 
ment of  Medicine;  Chief  Gynecolo^st,  Samaritan  Hospital;  Gyne- 
cologist, Garretson  Hospital;  Director,  Department  of  Public 
Health  and  Charities,  Philadelphia. 


(925) 


Diseases  of  the  Peritoneum. 


FOREWORD. 

The  treatment  of  peritonitis,  as  described  in  this  section, 
has  been  considered  from  the  standpoint  of  the  general  prac- 
titioner, and  not  from  the  viewpoint  of  the  specialist.  The 
physiolog-y  and  pathology  of  the  peritoneum  have  been  re- 
viewed only  in  so  far  as  they  may  assist  the  physician  in  ob- 
taining a  clear  and  comprehensive  understanding  of  the  prin- 
ciples underlying  the  rational  treatment  of  the  peritoneal 
diseases. 

Throughout  this  article  it  has  been  repeatedly  emphasized 
that  peritonitis  is  practically  always  associated  with  organic 
diseases,  and  that  the  treatment  must  necessarily  be  considered 
in  conjunction  with  the  primary  lesions  in  those  structures 
which  are  anatomically  and  physiologically  related  to  the 
lining  of  the  peritoneal  cavity. 

Each  case  must  be  treated  on  its  own  findings,  giving  due 
consideration  to  the  type  of  patient  and  to  the  resistance  to  the 
variet}^  of  infection  present. 

The  most  modern  and  accepted  methods  of  treatment  have 
been  described  as  practised  by  the  author  and  others  most 
qualified  to  speak  authoritatively  on  the  subject. 

ACUTE  GENERAL  PERITONITIS. 

General  Considerations.  In  order  that  one  may  fully  appre- 
ciate the  rational  treatment  of  peritonitis  of  all  types,  it  is 
essential  to  know  the  basic  facts  regarding  the  anatomic  struc- 
tures and  the  principles  of  the  physiology  of  the  peritoneum. 
This  structure  is  the  lining  membrane  of  the  abdominal  cavity, 
and  is  classified  among  the  serous  tissues,  being  occluded  from 
the  outside  of  the  body.  In  the  case  of  the  female,  however, 
there  is  a  direct  communication  through  the  fallopian  tubes. 
This  fact  should  be  borne  in  mind  when  considering  pelvic 
peritonitis,  which  in  many  instances  has  its  origin  by  way  of 
the  genital  tract. 

(927) 


928  DISEASES    OF    THE    PERITONEUM. 

The  peritoneal  cavity,  which  is  formed  by  the  folding  and 
dipping  of  this  serous  membrane,  is  divided  anatomically  into 
two  cavities,  called  the  greater  and  lesser  sacs,  the  former  be- 
ing that  portion  anterior  to  the  stomach  and  liver  wall,  and  the 
latter  lying  directly  behind  these  same  organs.  The  sacs  com- 
municate directly  with  one  another  through  the  foramen  of 
A\'insloAv.  Inflammator}-  conditions  in  one  sac  may,  therefore, 
spread  to  the  other.  That  portion  of  the  peritoneum  which 
covers  or  partly  covers  the  various  abdominal  viscera  is  known 
as  visceral  peritoneum,  while  that  which  lines  the  abdominal 
wall  is  termed  the  parietal.  This  differentiation  must  be  made 
because  inflammaton,-  conditions  of  either  portion  present  their 
special  symptoms.  AVhere  the  peritoneum  covers  an  organ,  it 
becomes  an  intricate  part  of  that  viscus,  helping  to  make  up 
the  structure,  and  by  strong  reduplication  holds  it  in  place. 
This  is  true  of  the  liver,  which  is  held  tightly  in  place  by  folds 
of  the  peritoneum  and  divided  into  lobes  by  invaginations  or 
dipping  down  of  the  peritoneum.  These  strong,  firm  bands  of 
tissue  derived  from  the  serous  lining  of  the  abdomen  play  an 
important  part  when  inflammator}-  conditions  arise  in  the 
region  of  the  liver,  being  better  able  to  resist  invasion 
than  parts  which  are  thin  and  less  resistant  to  pressure  and 
inflammation. 

The  omentum  is  the  largest  reduplication  of  the  peritoneum, 
and  acts  as  a  protective  covering  of  the  organs  behind  it. 
AA'hen  the  abdominal  viscera  are  invaded  by  disease,  this  apron 
of  tissue  with  its  supply  of  fat  acts  as  a  bulwark  of  defense  in 
the  attempt  to  limit  inflammatory  processes  by  the  extravasa- 
tion of  serum,  fibrin,  leucocytes,  and  by  matting  together  the 
tissues  about  the  affected  parts. 

Absorptive  Poiver  of  the  Peritoneum.  The  peritoneum  is  a 
lymph  sac,  being  capable  of  excreting  and  absorbing  fluid.  It 
has  been  described  as  a  large  joint,  lined  with  synovial  mem- 
brane, and  containing  a  serous  fluid.  Because  of  its  extensive 
area,  its  absorptive  power  is  said  to  be  very  great,  and  may 
increase  the  body-weight  fully  10  per  cent,  in  thirty  minutes  by 
the  absorption  of  hypotonic  salt  solution.  Advantage  of  this 
function  is  taken  in  the  treatment  of  peritonitis  by  the  use  of 
enteroclysis.  In  the  region  of  the  diaphragm  and  small  intes- 
tines absorption  is  greatest.  Infectious  and  toxic  material  when 


ACUTE   GENERAL    PERITONITIS.  929 

permitted  to  come  in  contact  with  these  portions  of  the  peri- 
toneum may  rapidly  invade  the  blood-stream  after  passing" 
through  the  larger  lymphatics.  These  parts  of  the  peritoneum 
are  called  the  danger  zones,  since  absorption  of  poisonous  ma- 
terials may  give  rise  to  generalized  blood-poisoning.  For  this 
reason  patients  are  placed  in  the  semi-recumbent  position  in 
order  to  keep  the  infectious  material  away  from  the  vital  parts 
of  the  peritoneum. 

The  Secretory  Function  of  the  Peritoneum.  An  albuminous 
fluid  is  secreted  by  the  peritoneum  in  sufficient  amount  to 
facilitate  the  motility  of  the  various  abdominal  organs.  The 
omentum  is  probably  the  most  active  part  of  the  peritoneum  in 
this  process  of  secretion,  and  plays  an  important  part  in  check- 
ing inflammation.  Robinson^  describes  it  as  "a  man-of-war 
ready  at  a  moment's  notice  to  move  to  invaded  parts.  It  cir- 
cumscribes abscesses,  repairs  visceral  wounds,  and  prevents 
adhesions  of  movable  viscera  to  the  abdominal  wall.  It  is  like 
a  moving  sentinel,  whose  beat  is  the  whole  peritoneal  cavity. 
It  is  a  diagnostic  aid  directing  the  surgeon  to  the  original  seat 
of  peritoneal  disease,  where  it  first  contracted  adhesions.  It 
closes  intestinal  wounds,  resists  infection  by  exudates,  and  does 
not  permit  absorption  of  sepsis.  It  is  a  storehouse  of  fat,  and 
acts  as  a  peritoneal  drain." 

Nerve  Supply.  Being  abundantly  supplied  with  nerves,  which 
regulate  the  caliber  of  the  blood-vessels,  and  hence  the  blood 
supply,  the  peritoneum  is  very  susceptible  to  shock.  Severe 
prostration  in  acute  peritonitis  may  be  explained  by  the  inti- 
mate supply  of  sympathetic  nerves,  causing  symptoms  in 
organs  distant  from  the  seat  of  trouble.  The  visceral  peri- 
toneum, being  more  abundantly  supplied  with  nerves  than  the 
parietal,  is  more  susceptible  to  shock.  Pain,  however,  comes 
chiefly  from  the  parietal  peritoneum,  which  is  supplied  by  sen- 
sory nerves,  branches  of  the  iliolumbar  and  the  last  two  thor- 
acic nerves.  The  visceral  peritoneum  is  comparatively  free  of 
sensory  nerve  supply.  Irritation  in  the  peritoneal  cavity,  there- 
fore, must  be  sufficient  to  reach  the  parietal  peritoneum  in 
order  to  cause  pain.  Inflammatory  conditions  mav  take  place 
in  the  liver,  gall-bladder,  ureter,  spleen,  or  urinary  bladder,  and 
give  no  pain  locally  until  the  parietal  peritoneum  is  afifected. 
When  a  stone  passes  through  the  ureter,  however,  the  impres- 

.'')9 


930  DISEASES    OF    THE    PERITONEUM. 

sion  is  carried  by  the  sympathetic  nerve  supply  to  the  cerebro- 
spinal nerves  by  way  of  the  spinal  cord,  and  the  pain  is  re- 
ferred to  the  groin.  In  the  case  of  gall-stones,  pain  is  usually 
referred  to  the  right  shoulder.  This  is  explained  by  the  fact 
that  the  impression  caused  by  the  stones  is  transferred  to  the 
diaphragm,  v^hich  is  in  close  proximity,  and  supplied  by  the 
phrenic  nerve,  having  its  root  in  the  fourth  cervical  segment 
of  the  cord.  The  nerves  supplying  the  right  shoulder  are  also 
derived  from  the  same  root.  Pain  travels  through  this  course 
from  the  gall-bladder  to  the  diaphragm,  to  the  cervical  cord, 
and  thence  to  the  shoulder.  Inflammatory  conditions  in  the 
abdomen  which  do  not  implicate  the  parietal  peritoneum,  there- 
fore, may  cause  pain  in  places  distant  from  the  seat  of  trouble. 
Lymphatics  of  the  Peritoneum.  Of  no  small  importance  are 
the  lymphatics  of  the  peritoneum.  They  are  very  active  in  the 
absorptive  function  of  the  abdomen,  and  are  most  plentiful 
surrounding  the  stomach,  liver,  and  pancreas,  less  numerous 
about  the  abdominal  aorta,  and  least  in  number  in  the  pelvis. 
Absorption  will  thus  be  greatest  in  the  upper  abdomen,  and 
least  in  the  pelvis.  Advantage  is  taken  by  the  surgeon  of  this 
distribution  of  the  lymphatics  by  placing  the  patient  suffering 
from  profuse  inflammation  of  the  peritoneum  in  such  a  position 
that  the  toxic  products  will  gravitate  to  the  dependent  portions 
of  the  abdomen,  where  little  or  no  absorption  takes  place.  The 
semi-recumbent  posture  is,  therefore,  adopted  in  septic  condi- 
tions of  the  abdomen,  this  being  known  as  the  Fowler  position. 

Summary  of  Peritoneal  Functions: 

1.  Absorption,  which  takes  place  by  (a)  lymphatics;  (&) 
veins,  probably  through  peritoneal  pressure,  w^hich  is 
greater  outside  the  veins ;  (c)  osmosis,  by  direct  action 
of  the  endothelial  cells. 

2.  Secretion,  which  takes  place  by  exudation  from  the 
venous  capillaries. 

3.  Supportive,  (a)  Acting  as  suspensory  ligaments  for 
the  liver,  stomach,  and  intestines;  (b)  encapsulating 
the  pancreas,  and  adding  support  to  the  large  intes- 
tine, bladder,  and  uterus. 

The  leading  facts  of  the  clinical  pathology  of  acute  diffuse 
peritonitis  relate  to   a  uniform  distention   of  the   intestines. 


ACUTE   GENERAL   PERITONITIS.  931 

Some  areas  beiiii^-  more  affected  than  others,  arc  distended  wit'.i 
gas  and  matted  together  by  exudate.  Depending-  upon  the 
severity  of  the  infection,  tlie  exudate  may  be  serous,  in  which 
the  irritant  producing-  the  inflammation  causes  an  excessive 
transudation  of  peritoneal  fluid.  When  the  irritation  is  still 
greater,  causing  precipitation  of  fibrin  in  addition  to  the  serum 
already  present,  the  exudation  is  then  called  serofibrijions.  The 
proportion  of  serum  and  fibrin  will  vary,  and  eitlier  may  pre- 
dominate. If  the  inflammatory  condition  is  still  more  violent, 
leucocytes  are  called  into  play,  which  migrate  through  the 
walls  of  the  blood-vessels  and  cause  the  exudate  to  become 
■milky,  creamy,  or  greenish-yellow,  depending  upon  the  pres- 
ence of  various  bacteria.  This  type  is  known  as  the  purulent 
variety.  The  amount  of  pus  formation  is  dependent  upon  the 
severity  of  the  irritation,  the  resistance  of  the  patient,  and  the 
type  of  prevalent  micro-org'anism.  The  staphylococcus  im- 
parts a  yellowish  or  creamy  color  to  the  pus,  the  pyocyaneus 
gives  a  greenish  color,  while  the  bacillus  prodigiosus  imparts  a 
red  color.  Usually  there  is  mixed  infection,  and  the  color  of 
the  pus  depends  upon  the  predominating  micro-organism. 
When  bleeding  occurs,  caused  by  the  rupture  of  blood-vessels, 
the  blood  is  intimately  mixed  with  the  exudate,  which  is  then 
termed  hemorrhagic.  Any  of  the  previous  types  may  later  be- 
come hemorrhagic. 

The  micro-organisms  found  in  acute  general  peritonitis  may 
be  of  many  types,  the  most  common  being  the  staphylococcus, 
streptococcus,  colon  bacillus,  and  less  frequently  the  pneumo- 
coccus,  g-onococcus,  and  bacillus  lactis  aerogenes.  In  this  con- 
nection the  common  forms  only  will  be  described.  Mention. 
however,  may  be  made  of  the  pneumococcic  infections,  which 
have  received  greater  attention  of  late  owing  to  the  new  classi- 
fication of  this  bacterium  into  four  types,  as  described  by  Cole, 
each  of  which  has  special  characteristics  in  morpholog}^  and 
virulence.  Our  frequent  winter  epidemics  of  pneumonia,  at- 
tended with  a  high  mortality  rate,  may  account  for  many  of 
the  infections  of  the  intestinal  tract  with  this  micro-org-anism. 
Type  I.  and  type  II.  pneumococci  have  been  found  most  fre- 
quently in  acute  pulmonary  infections,  and  there  is  reason  to 
believe  that  .the  same  type  may  be  found  in  acute  peritoneal 
infections. 


932  DISEASES   OF   THE   PERITONEUM. 

There  are  no  definitely  defined  symptoms  of  general  peri- 
tonitis, for  "the  reason  that  they  will  vary  with  the  organs 
affected,  the  type  of  micro-organism  which  predominates,  and 
the  resistance  of  the  patient.  Children  present  different  symp- 
toms from  those  observed  in  the  aged ;  the  streptococcus  pro- 
duces a  more  overwhelming  inflammation  than  the  colon  bacil- 
lus ;  and,  briefly,  the  symptoms  vary  according  to  the  organ 
chiefly  damaged,  and  the  weak  will  present  different  reactions 
than  the  strong. 

We  must,  therefore,  look  upon  acute  general  peritonitis  as 
the  result  of  the  reaction  of  the  peritoneum  against  invading 
poisons,  some  of  which  have  been  absorbed  by  the  blood,  caus- 
ing- a  series  of  local  and  general  constitutional  symptoms. 

When  the  entire  peritoneum  is  inflamed,  which  is  nearly 
always  true  of  a  mixed  infection,  the  intensity  of  the  symp- 
toms will  var}"  with  the  predominating  micro-organism. 

The  streptococcus  causes  the  most  violent  type  of  infection. 
It  produces  a  large  amount  of  toxin,  which  is  set  free  and  ab- 
sorbed. The  resulting  symptoms  will  necessarily  be  high 
fever,  ranging  from  103°  to  105°  F.  (39.5°  to  40.6°  C),  depend- 
ing upon  the  toxic  effect  upon  the  thermogenic  centers,  and  the 
pulse  will  be  full  and  bounding.  The  severe  irritation  causes 
abundant  serous  exudate  to  be  poured  out,  distention  of  the 
abdomen,  and  induration  of  the  abdominal  walls.  The  intes- 
tines are  "splinted"  and  matted  down  by  the  exudate,  which  is 
Nature's  method  of  protecting  the  abdominal  viscera  from 
irritation.  Peristalsis  is  thereby  hindered,  resulting  in  consti- 
pation, distention  by  gas,  and  a  general  sense  of  fullness  of  the 
entire  abdomen.  AA'hen  this  distention  becomes  so  great  as  to 
exert  pressure  upon  the  stomach,  it  produces  a  feeling  of  nau- 
sea, which  later  leads  to  vomiting.  Continued  obstruction  of 
the  normal  peristaltic  movements,  with  excessive  generation  of 
intestinal  gases,  causes  reversed  peristalsis  and  vomiting  of 
ordinary  stomach  contents,  of  bile,  and  even  of  fecal  material. 

The  stomach  normallv  eliminates  poisonous  products  from 
the  body,  just  as  in  the  case  of  morphin  poisoning,  when  this 
drug  can  be  found  in  the  stomach  contents.  In  general  toxemia 
caused  by  peritonitis,  the  stomach  also  attempts  to  eliminate 
the  poisonous  products,  and  in  so  doing  the  toxins,  may  cause 
the  capillar}'  blood-vessels  to  rupture,  resulting  in  the  extra- 


ACUTE   GENERAL    PERITONITJS.  933 

vasation  of  blood,  and  accounting'  for  the  bloody  vomitus  in 
advanced  cases  of  general  peritonitis.  The  dark-brown  coffee- 
ground  appearance  is  due  to  the  action  of  the  gastric  juices 
upon  the  blood.  When  the  vomitus  contains  blood,  we  are 
assured  that  we  are  dealing  with  a  very  severe  fulminating 
phlegmonous  type  of  infection,  and  if  further  progress  of  the 
disease  is  not  arrested  immediately,  the  blood  system  is  over- 
whelmed with  poisons,  the  antibodies  are  overcome  by  the 
toxins,  and  we  have  a  condition  of  general  septicemia,  which 
may  cause  immediate  death. 

The  colon  bacillus  infection,  on  the  other  hand,  causes 
symptoms  which  are  directly  opposite  to  those  of  the  strepto- 
coccus. Instead  of  a  violent,  rapid  and  reactive  infection,  the 
symptoms  are  very  insidious  in  onset.  The  toxins  are  only 
mildly  irritating,  and  produce  a  slow  but  certain  poisoning  of 
the  system.  The  pulse  may  be  slow,  of  small  volume,  and  low 
tension.  Symptoms  of  a  slowly  depressing  character  may  con- 
tinue over  a  long  period  of  time,  attended  by  loss  of  weight, 
sallow  complexion,  neurasthenia,  and  loss  of  mental  and 
physical  activity.  These  indefinite  symptoms  may  hide  the 
true  inflammatory  condition,  until  a  slowly  forming  abscess  in 
any  part  of  the  abdomen  ruptures  and  ushers  in  the  acute  mani- 
festations of  peritonitis.  Throughout  the  inflammatory  process 
a  normal  or  even  subnormal  temperature  may  be  recorded,  and 
little  or  no  pain  complained  of  in  spite  of  the  continued  de- 
pressing action  of  the  toxins. 

The  staphylococcus  infection  gives  rise  to  symptoms  mid- 
way between  those  of  the  streptococcus  and  the  colon  bacillus 
varieties.  The  fever  is  not  very  high,  the  pulse  may  be  strong 
or  even  normal,  the  pain  is  slight,  and  the  digestive  symptoms 
merely  enough  to  indicate  a  mild  inflammatory  process.  There 
may,  however,  be  several  micro-organisms  responsible  for  the 
peritoneal  infection,  in  which  case  the  predominating  germ  is 
manifested  by  its  specific  symptoms.  This  is  known  as  the 
mixed  infection,  which  is  probably  the  most  frequent  variety. 

Presupposing  a  typical  case  of  acute  general  peritonitis,  the 
early  cardinal  symptoms  will  be  pain,  fever,  nausea,  constipation, 
tympanites,  and  abdominal  distention. 

These  symptoms  correspond  exactly  with  those  of  tvphoid 
fever,  with  the  exception  that  in  the  latter  disease  the  fever 


934  DISEASES    OF    THE    PERITOXEUM. 

makes  its  appearance  early,  and  the  pain,  which  is  not  very 
severe,  late. 

Leucocyfosis  as  a  Diagnostic  Symptom.  The  increase  in  the 
number  of  leucocytes  in  the  blood  is  the  direct  result  of  a  vio- 
lent reaction  caused  by  foreign  products  in  the  body.  In  the 
early  stage  of  general  peritonitis,  leucocytosis  may  not  be  very 
marked,  but  the  relatively  large  percentage  of  polymorpho- 
nuclear cells  should  be  regarded  as  a  significant  diagnostic 
sign  of  an  acute  inflammator}-  process.  As  the  disease  pro- 
gresses, howe\"er,  an  increased  number  of  leucocytes  is  called 
into  action,  when  the  leucocytosis  may  reach  40.000  to  50,000, 
with,  a  preponderance  of  polymorphonuclear  cells,  averaging 
80  to  90  per  cent  This  is  especially  true  when  the  infection  of 
the  peritoneum  has  become  generalized  and  is  caused  by  the 
streptococcus.  A  low  leucocyte  count  in  a  patient  who  pre- 
sents ^^'eak  cardiac  sounds,  marked  physical  depression  and 
prostration,  feeble  pulse,  with  little  or  no  pain,  no  distention  of 
the  abdomen,  and  no  apparent  rigidit}^  of  the  abdomen,  should 
lead  to  the  suspicion  of  infection  with  the  colon  bacillus.  The 
surgeon  must,  therefore,  be  on  his  guard  not  to  disregard  a 
low  leucocyte  count  or  to  be  misled  into  believing  that  no  in- 
fection is  present.  On  the  contrary,  the  inflammatory  process 
may  be  general,  and  the  toxins  present  of  such  a  nature  as  to 
be  inactive  in  calling  out  the  leucocytes.  In  cases  of  marked 
collapse,  or  where  the  patient  is  feeble,  no  leucocytosis  is  to  be 
expected,  and  yet  the  patient  may  die  without  any  reactive  in- 
flammatory signs,  without  fever  and  without  pain,  but  by  slow 
and  gradual  poisoning.  The  absence  of  leucocytosis,  therefore, 
may  mean  a  mild  inflammation  or  a  severe  infection  of  high 
toxic  nature,  with  feeble  resistance  on  the  part  of  the  pa~ 
tient.  A  high  count,  on  the  other  hand,  always  indicates  a 
severe  infection  with  adequate  reaction  by  the  patient.  A  high 
count  calls  for  immediate  operation ;  a  low  count,  with  signs 
of  severe  prostration,  calls  even  more  urgently  for  immediate 
operative  interference. 

Symptoms  FoUon'^i.ng  Early  Stage.  After  fort\^-eight  hours 
of  pain,  fever,  muscular  rigidity,  nausea  and  distention,  gen- 
eral symptomatic  treatment  may  cause  these  symptoms  to 
remit,  and  the  patient  may  apparently  feel  relieved.  Such  re- 
lief, however,  may  be  only  temporary,  and  the  case  may  con- 


ACUTE  (;i':N'Kk/\i.  j-kuitoxitis.  935 

tinue  on  with  cold  sweats,  pinched  facial  expression,  sunken 
eyes,  sighing  respiration,  and  intense  rigidity  of  the  abdomen ; 
the  pulse  becomes  weak,  and  the  temperature  may  even  be- 
come subnormal.  This  group  of  symptoms  should  be  recog- 
nized as  those  of  shock,  which  is  the  result  of  the  severe  im- 
pression made  by  the  general  toxemia  upon  the  nervous  sys- 
tem. Even  in  this  condition  the  patient's  mind  may  be  clear 
and  the  memory  good.  A  similar  picture  often  is  seen  in  the 
advanced  state  of  cholera,  known  as  the  algid  stage.  For  this 
reason  the  same  name  has  been  applied  to  the  exhausted  state 
in  advanced  acute  general  peritonitis.  In  the  colon  bacillus 
infection  this  algid  stage  is  often  presented  without  any  pre- 
vious violent  reactive  symptoms. 

Cause  0/  Death  in  Acuie  General  Peritonitis.  Septicemia  is 
usually  the  cause  of  death  in  general  infection  of  the  peri- 
toneum. The  invasion  of  the  blood-stream  by  pathogenic 
micro-organisms  and  their  toxins  is  the  result  either  of  slow 
absorption,  as  in  the  case  of  colon  bacillus  infection,  or  is  rapid 
and  abrupt  as  in  a  streptococcus  infection.  In  either  variety 
there  is  an  exhaustion  of  the  antibodies  in  the  blood  or  an 
overproduction  of  toxins  when  septicemia  occurs. 

Subacute  General  Peritonitis.  When  infection  takes  place 
in  a  robust  individual,  the  reaction  may  not  be  very  violent, 
and  several  days  may  elapse  before  acute  symptoms  are  mani- 
fest. In  cases  \vhere  there  is  a  local  peritonitis,  or  an  oozing 
from  a  ruptured  viscus,  the  general  peritonitis  takes  place 
slowly,  and  the  reaction  on  the  part  of  the  patient  responds  to 
the  steady  flow  of  infection.  The  symptoms,  therefore,  cor- 
respond in  name  to  those  of  the  acute  variety,  but  will  be  less 
severe  in  character.  Moreover,  in  the  case  of  the  slow  infect- 
ing process  more  time  is  allowed  for  adhesions  to  form  about 
the  inflammatory  area,  thereby  lessening  the  extent  of  the  in- 
flammation and  the  severity  of  the  clinical  picture. 

Sources  of  General  Peritonitis.  Infection  of  the  peritoneum 
may  arise  from  causes  wthin  the  digestive  tract,  such  as  a  per- 
forated typhoid  ulcer,  a  perforated  gastric  ulcer,  intestinal  ob- 
struction and  gangrene  of  the  intestines ;  or  from  causes  out- 
side of  the  digestive  tract,  such  as  perforating  wounds  of  the 
abdomen,  rupture  of  the  urinary  or  gall-bladder,  extension  of 
the  inflammatory  process  from  the  kidney,  pancreas,  spleen. 


936  DISEASES    OF   THE    PERITONEUM. 

uterus,  and  from  rupture  of  a  localized  peritoneal  abscess.  The 
common  abdominal  abscesses  are  :  appendiceal,  subphrenic,  and 
pelvic.  Extravasation  of  the  intestinal  or  the  gastric  contents 
may  cause  a  general  or  localized  peritonitis,  depending  upon 
the  resistance  of  adhesions  already  formed  about  the  inflamed 
parts,  and  the  intensity  of  the  infection  w^ill  depend  upon  the 
predominating  micro-organism  present.  In  the  case  of  a  rup- 
tured appendiceal  abscess,  encapsulated  only  by  a  thin  fibrous 
wall,  a  severe,  violent,  and  rapidly  spreading  peritonitis  may 
take  place.  On  the  other  hand,  should  this  abscess  be  confined 
by  a  toug'h  resisting  fibrous  wall,  which  by  degenerative  proc- 
ess presents  a  leak,  the  extravasation  of  its  contents  will  neces- 
sarily be  gradual,  and  the  abdomen  by  its  natural  process  will 
take  care  of  this  infection  by  newdy  formed  adhesions.  The 
symptoms,  therefore,  tend  to  be  of  mild  character  and  less 
toxic. 

When  the  pancreas  is  ruptured  as  the  result  of  pathologic 
changes,  its  chemical  secretions  are  extravasated  into  the  peri- 
toneal cavity,  and  by  their  digestive  action  bring  about  an 
acute  inflammatory  peritonitis. 

When  obstruction  of  the  bowel  occurs,  either  by  invagina- 
tion of  the  intestines,  twisting  of  the  gut,  constriction,  or  pres- 
sure, the  blood  supply  of  the  parts  affected  is  immediately  shut 
off,  resulting  in  gangrenous  degeneration.  The  intestinal  bac- 
teria are  then  free  to  migrate  through  the  intestinal  walls  into 
the  peritoneal  cavity,  where  an  acute  inflammatory  process 
takes  place. 

In  embolism  of  the  mesenteric  artery  a  change  results 
similar  to  that  just  described  in  obstruction  of  the  bowel.  The 
abdominal  viscera  supplied  by  this  artery  becomes  gangrenous, 
and  the  invading  micro-organisms  attack  the  peritoneal  lining. 

Inflammatory  processes  are  quite  often  localized  when  the 
affected  parts  are  situated  so  as  to  be  protected  by  the  sus- 
pensory ligaments  formed  by  the  reduplication  of  the  peri- 
toneum. This  is  especially  true  In  the  region  of  the  liver, 
where  infection  usually  results  in  the  formation  of  a  sub- 
phrenic abscess. 

Acute  perforations  of  the  stomach  and  bowel  may  become 
plugged  by  the  adjacent  omentum,  which  checks  any  spread 
of  intestinal  or  gastric  contents  by  the  exudation  of  serum  and 


ACUTE    GENERAL    PERITONITIS.  937 

fibrin,   thus   localizing  the   infection   and   preventing-  a  wide- 
spread peritonitis. 

TREATMENT. 

Each  individual  case  must  be  treated  according  to  its  own 
merits.  The  young  and  the  old,  the  robust  and  the  weak,  will 
necessarily  present  different  types  of  cases.  Due  consideration 
must  be  given  to  the  fact  that  the  disease  alone  is  not  being 
treated,  but  the  disease  in  a  particular  individual.  Every  case 
of  general  peritonitis  has  a  definite  focus  of  infection.  The 
treatment,  therefore,  should  begin  long  before  the  infection  has 
affected  the  whole  peritoneal  cavity.  In  other  words,  by  re- 
moving a  local  infection  in  the  peritoneal  cavity,  a  general  in- 
flammatory process  may  be  aborted. 

When  the  entire  peritoneum  is  implicated,  however,  the 
first  aim  in  treatment  is  to  "splint"  the  intestines.  This  may 
.be  accomplished  by  withholding  food  and  drink  of  all  kinds. 
In  the  absence  of  intestinal  contents,  peristalsis  is  necessarily 
reduced.  Cathartics  must  be  avoided,  because  any  movement 
by  the  bowel  must  tend  to  disseminate  the  infection  in  the  ab- 
domen and  bring  about  an  unfavorable  condition.  The  physi- 
cian must  not  be  tempted  to  administer  opiates  or  their  deriva- 
tives to  allay  pain  or  to  reduce  peristalsis.  While  the  adminis- 
tration of  narcotics  may  relieve  the  patient,  it  is  only  apparent 
and  temporary.  Furthermore,  narcosis  masks  the  true  symp- 
toms, which  are  the  surgeon's  indicators  as  to  the  time  for 
operative  interference.  Under  the  influence  of  morphin  an  ap- 
pendiceal abscess  may  rupture  without  giving  the  usual  diag- 
nostic symptoms,  and  thus  permit  a  rapid  dissemination  of  the 
infection.  It  is,  therefore,  a  dangerous  procedure  to  administer 
narcotics  in  the  treatment  of  acute  general  peritonitis.  Should 
the  physician  decide  to  adopt  surgical  interference,  however, 
then,  and  only  then,  is  it  advisable  to  give  a  hypodermic  injec- 
tion of  morphin.  Under  its  influence  the  patient  is  better  able 
to  undergo  the  surgical  ordeal,  and  no  danger  exists  because 
the  abdominal  cavity  will  shortly  be  explored  by  the  surgeon. 

When  to  Operate.  If  the  symptoms  become  exaggerated  after 
the  patient  has  been  resting-  in  bed  for  twenty-four  hours  with- 
out food  and  drink,  then  no  time  should  be  lost  in  opening  the 
abdomen.  Should  the  symptoms  become  violent  and  fulmin- 
ating before  the  termination  of  the  first  twenty-four  hours,  and 


938  DISEASES    OF   THE   PERITONEUM. 

the  patient  is  in  severe  pain,  or  in  a  state  of  shock,  interference 
should  be  made  at  once.  Delay  even  for  one  hour  may  prove 
fatal  in  violent  infections  resulting  from  a  ruptured  abscess, 
acute  obstruction  of  the  bowel,  or  rupture  of  one  of  the  ab- 
dominal viscera.  ]\Iedical  treatment  is  only  suggested  when 
the  inflammatory  process  is  mild  and  the  symptoms  are  station- 
ary or  are  regressing.  It  is  an  error  to  wait  for  absolutely 
definite  indications.  When  in  doubt,  always  operate.  The 
danger  lies  not  in  the  operation,  but  in  the  failure  to  operate. 
Very  often,  however,  the  surgeon  receives  the  case  too  late  for 
surgical  interference.  The  medical  practitioner  should  always 
consider  the  advisability  of  operative  measures  first,  and  medi- 
cal treatment  onl}^  as  a  temporary-  substitute.  Statistics  and 
experience  prove  that  the  mortality  rate  of  peritonitis  is  di- 
rectly proportional  to  the  time  of  operation.  The  earlier  the 
operative  measures  are  adopted  the  less  is  the  death-rate. 

The  treatment  of  acute  general  peritonitis  is  surgical. 
While  a  few  mild  cases  may  be  carried  along,  and  even  get 
well,  by  medical  treatment,  the  adoption  of  such  a  procedure 
is  dangerous  to  life.  The  time  to  operate  is  early,  and  the 
earlier  the  better  the  prognosis.  Never  treat  a  case  of  general 
infection  more  than  forty-eight  hours  by  medical  means.  If  no 
signs  of  improvement  occur,  and  the  infection  is  violent,  the 
surgeon  should  not  even  wait  one  hour  before  operating. 

Surgical  Treatment.  An  incision  is  made  in  the  median  line, 
the  abdomen  opened,  and  a  careful  examination  made  for  the 
local  seat  of  trouble.  The  viscera  should  be  handled  gently  in 
order  to  prevent  the  spread  of  infection  to  other  parts  and  to 
avoid  shock.  Inspection  should  be  made  of  the  appendix, 
stomach,  gall-bladder,  intestines,  and,  in  the  female,  of  the  fal- 
lopian tubes.  It  should  be  remembered  that  more  than  one 
condition  may  exist  at  the  same  time,  and  the  surgeon  must  not 
be  content  with  the  finding  of  one  single  lesion.  The  treatment 
of  general  peritonitis  is,  in  short,  the  removal  of  the  cause. 

The  technic  of  the  various  operations  will  not  be  discussed 
here.  If  there  be  a  perforation  of  the  stomach  or  intestines, 
this  must  be  closed;  and  if  the  appendix  is  diseased,  it  should 
be  removed.  An  abscess  should  be  opened  and  drained,  and  a 
gangrenous  gut  must  be  resected  and  the  healthy  segments 
■united. 


ACVTE   GRX^ERAL   fRRITOXlTt?^.  930 

To  Drain  ur  Nut  to  Drain.  A  general  infection  indicates  that 
the  inllammatory  process  has  already  extended  beyond  the 
local  source  of  the  disease.  It  becomes  necessary,  therefore, 
to  drain  off  the  toxic  products  which  remain  in  the  peritoneal 
cavity.  If  the  infection  has  been  a  slow  one,  occurring  in  a 
robust  patient  with  good  bodily  resistance,  drainage  is  not 
necessary,  for  the  vital  powers  of  the  patient  may  be  sufficient 
to  take  care  of  the  abdominal  infection.  Every  case  of  severe 
and  extensive  peritonitis  calls  for  drainage.  Every  infection 
in  persons  who  are  physically  weak,  and,  in  the  judgment  of 
the  surgeon,  are  unable  to  take  care  of  the  inflammatory  pro- 
cess, should  be  drained.  The  question  of  drainage,  therefore, 
rests  with  the  nature  of  the  infection  and  the  type  of  the 
patient. 

Drainage  of  the  abdomen  should  be  performed  (1)  if  the 
patient  is  weak ;  (2)  if  there  is  a  fulminating  infection  present, 
as  shown  by  the  character  of  the  symptoms  and  the  absence  of 
adhesions  about  the  source  of  inflammation;  (3)  if  there  are 
abscesses  in  the  various  abdominal  fossae  or  between  the 
knuckles  of  gut;  (4)  if  after  removing  the  cause  there  is  still 
pus  or  gangrenous  tissue  left  behind;  and  (5)  when  in  doubt. 

How  to  Drain.  Plain  sterile  gauze  may  be  used  to  drain  the 
abdominal  cavity  of  its  infectious  material.  This  acts  as  a 
lamp  wick,  carrying  the  septic  products  from  the  seat  of  dis- 
ease to  the  outside  of  the  abdomen.  The  constituents  of  this 
inflammatory  product  soon  clog  up  the  interstices  of  the  gauze 
as  the  result  of  fibrin  formation,  thus  hindering  further  drain- 
age. The  gauze  drain  accomplishes  its  purpose,  however,  dur- 
ing the  first  twenty-four  hours  before  fibrin  formation  is  com- 
plete. Failure  to  remove  gauze  packing  which  has  become 
saturated  with  pus,  blood,  serum,  and  fibrin,  after  twenty-four 
hours  of  use,  may  act  as  a  plug  rather  than  as  a  wick,  and  thus 
hinder  the  entire  purpose  of  drainage.  When  packing  is  used 
for  the  purpose  of  walling  ofif  infection,  removal  is  not  neces- 
sary, because  the  presence  of  the  gauze  is  intended  to  stimulate 
the  formation  of  new  fibrous  tissue. 

Sufificient  gauze  drainage  should  be  used  to  cover  all  raw 
surfaces  surrounding  the  local  area  of  infection,  and  should 
be  long  enough  to  reach  beyond  the  abdominal  wound.  Pro- 
tection of  the  parietal  peritoneum  and  the  wound  itself  may  be 


940  DISEASES   OF   THE   PERITONEUM. 

accomplished  by  the  use  of  a  rubber  dam  so  wrapped  about  the 
gauze  as  to  prevent  the  contact  of  the  latter  with  the  abdominal 
wound.  Such  a  drain  is  sometimes  called  a  cigarette  drain. 
Attention  should  be  given  especially  to  local  pockets,  w'here 
infectious  material  may  find  lodgment,  as  in  the  case  of  the 
iliac  fossa.  AMien  the  infection  is  severe,  and  a  large  amount 
of  pus  is  found  in  the  abdomen,  a  counter-puncture  may  be 
made  in  the  median  line,  just  above  the  pubic  bone,  and  a  glass 
tube  inserted  reaching  the  cul-de-sac  of  Douglas. 

Another  method  of  draining  the  abdomen  of  its  toxic 
products  is  the  continuous  instillation  of  normal  saline  solution 
into  the  bowel,  where  the  fluids  are  absorbed  and  eliminated 
through  the  open  abdominal  wound  and  through  the  kidneys. 
This  is  known  as  the  "jMurph^^  enteroclysis."  The  method  of 
using  this  drainage  can  best  be  described  by  repeating  the 
words  of  Dr.  Murphy  himself: 

''As  soon  as  the  patient  is  returned  to  bed  after  operation, 
proctoclysis  is  instituted,  and  maintained  until -the  serious 
symptoms  of  intoxication  cease.  The  continuous  method  is  by 
far  the  most  scientific  and  successful.  IModerate  distention  is 
the  normal  condition  of  the  large  intestine.  If  it  is  hyperdis- 
tended,  it  causes  spasm  and  expulsion  of  material.  The  mucosa 
of  the  large  intestine  absorbs  water  \vith  great  rapidity.  The 
retention  of  fluid  in  the  colon  depends  entirely  upon  the  method 
of  its  administration.  We  have  visited  hospitals  numbers  of 
times,  and  have  been  shown  patients  who  are  receiving  the 
Murphy  treatment.  AVe  should  not  have  recognized  it  without 
the  label.  It  is  difficult  to  impress  those  administering  it  with 
the  importance  of  detail,  notwithstanding  that  the  best  results 
are  secured  only  by  close  attention  to  detail.  A  fountain 
syringe,  to  which  is  attached  a  three-eighths-inch  rubber  hose, 
fitted  with  a  hard  rubber  or  glass  vaginal  douche  tip  with  mul- 
tiple openings,  was  the  medium  originally  used.  The  tube 
should  be  flexed  almost  to  a  right  angle  three  inches  from  its 
tip.  A  straight  tube  must  not  be  used,  as  the  tip  produces  pres- 
sure on  the  posterior  wall  of  the  rectum  when  the  patient  is  in 
the  Fowler  position.  The  tube  is  inserted  into  the  rectum  to  the 
flexion  angle,  and  secured  in  place  by  adhesive  strips  binding  it, 
to  the  side  of  the  thigh,  so  that  It  cannot  come  out ;  the  rubber 
tubing  is  passed  under  the  sheet  to  the  head  or  foot  of  the  bed 


ACUTE   GENERAL    PERITONITIS. 


941 


to  which  the  fountain  is  attached.  It  should  be  suspended 
from  six  to  fourteen  inches  above  the  level  of  the  buttocks,  and 
raised  or  lowered  to  just  overbalance  hydrostatically  the  intra- 
abdominal pressure — i.e.,  it  must  be  just  high  enough  to  re- 
quire from  forty  to  sixty  minutes  for  one  and  one-half  pints  to 
flow  in,  the  usual  quantity  given  every  two  hours.  The  flow 
must  be  controlled  by  gravity  alone,  and  never  by  a  forceps  or 
constriction  on  the  tube,  so  that  when  the  patient  endeavors  to 
void  flatus  or  strain,  the  fluid  can  rapidly  flow  back  into  the 
can ;  otherwise  it  will  be  discharged  into  the  bed.  Tt  is  this 
ease  of  flow  to  and  from  the  bowel  that  insures  against  over- 
distention  and  expulsion    on  to  the  linen. 


Fig.  1. — Enteroclj^sis  apparatus,  showing  attachment  to  side  of  bed. 


"The  fountain  had  better  be  a  glass  or  graded  can,  so  that 
the  flow  can  be  estimated.  The  temperature  of  the  water  in  the 
fountain  can  be  maintained  at  100°  by  casement  in  hot-water 
bags.  The  fountain  is  refilled  every  two  hours  with  one  and 
one-half  pints  or  two  pints  of  solution.  The  tube  should  not 
be  removed  from  the  rectum  for  two  or  three  days,  except  for 
bowel  movement.  When  the  nurse  complains  that  the  solu- 
tion is  not  being  retained,  it  is  certain  that  it  is  not  being  prop- 
erly given ;  even  children  tolerate  proctoclysis  surprisinglv 
well.  We  have  administered  as  much  as  thirty  pints  of  salt 
solution  in  twenty-four  hours,  and  it  was  all  retained.    A\>  be- 


942  DISEASES    OF   THE    PERITONEUM. 

lieve  that,  next  to  the  conservative  technic  of  the  operative  pro-. 
cedure,  proctoclysis  is  second  in  importance  as  a  life-saver.  It 
rapidly  restores  blood-pressure,  it  improves  the  capillary  cir- 
culation, it  quiets  the  thirst,  it  eliminates  the  septic  products 
and  increases  the  secretions.  All  the  details  are  simple,  but 
thev  must  be  carried  out  with  precision  to  secure  the  best 
results." 

Gastric  Lavage.  Having  assisted  nature  by  drawing  off  the 
infectious  agents  of  the  peritoneal  cavity  by  means  of  gauze 
wicks  and  by  dilution  of  toxic  products  through  the  use  of 
enteroclysis,  we  also  attempt  to  remove  the  poisonous  agents 
through  the  stomach,  which  organ  is  ver}-  active  in  itself  in 
throwing  off  foreign  substances  from  the  abdomen.  Evidence 
of  this  elimination  is  shown  by  vomiting  during  the  acute  stage 
of  the  disease.  The  marked  depression  of  the  patient  after 
operation  or  during  early  couA-alescence  can  be  attributed  to 
the  efforts  of  the  stomach  in  eliminating  toxic  products  of  the 
abdomen.  By  washing  out  the  stomach,  however,  immediately 
after  operation,  the  toxic  products  are  rapidly  disposed  of,  and 
physical  depression  is  thereby  avoided.  Gastric  laA'age  is  an 
essential  part  of  the  so-called  "Ochsner  treatment,"  which  aims 
to  abate  the  abdominal  infection  by  withholding  all  food, 
thereby  reducing  intestinal  peristalsis,  and  by  eliminating 
infectious  products  through  the  stomach.  By  washing  out  the 
stomach,  reverse  peristalsis  is  checked,  vomiting  ceases,  and 
there  is  a  general  decline  of  all  the  constitutional  sj^mptoms, 
together  with  a  tendency  of  the  infection  to  localize  itself  at 
its  seat  of  origin.  A^omiting  will  continue  if  the  stomach  con- 
tains the  slig-htest  amount  of  intestinal  products  or  poisons  ab- 
sorbed from  the  peritoneum.  Lavage  must  therefore  be  con- 
tinued at  repeated  interA^als  until  the  irritability  of  the  stomach 
ceases. 

The  technic  of  gastric  lavage  may  be  described  as  follows : 
The  patient  is  placed  on  his  side  and  the  throat  sprayed  with 
a  4  per  cent,  solution  of  cocain  two  or  three  times  within  a 
period  of  five  minutes.  The  stomach-tube,  after  a  thorough 
cleansing,  is  placed  in  a  basin  containing  cracked  ice  or  ice 
water,  remaining  so  immersed  until  it  is  thoroughly  cool.  The 
tip  of  the  tube  is  then  placed  in  the  mouth  and  gently  directed 
toward  the  pharynx.    The  patient  is  requested  to  swallow  re- 


ACUTE    GENERAL    PERITONITIS.  943 

peatedly,  until  the  esophageal  muscles  take  a  firm  hold  on  the 
tube,  guiding  it  into  the  stomach.  That  portion  of  the  tube 
remaining  outside  is  lowered  in  order  to  siphon  off  the  stomach 
contents.  A  pint  (473  mils)  of  warm  water  or  saline  solution 
is  poured  into  the  stomach,  and  then  siphoned  ofif.  This  may 
be  done  repeatedly  until  the  siphon  liquid  returns  clear. 

Gastric  lavage  "may  be  performed  before  and  after  operation, 
and  in  cases  of  acute  gastric  dilatation,  which  sometimes  occurs 
after  general  anesthesia.  It  must  be  repeated  also  until  the 
acute  threatening  symptoms  subside.  The  contraindications  of 
gastric  lavage  are  carcinoma  and  ulcer  of  the  stomach. 

Feeding  and  Stimulation.  Prior  to  operation  all  food  and 
drink  should  be  absolutely  withheld.  Feeding  increases  the 
burden  on  the  stomach,  tends  to  produce  vomiting  and  abdom- 
inal distention,  and  may  aggravate  the  constitutional  symp- 
toms. Following  operation,  all  food  is  withheld  until  the  acute 
distressing  symptoms  have  subsided.  Thirst  is  controlled, 
however,  by  enteroclysis,  and  the  dryness  of  the  lips  may  be 
overcome  by  moistening  them  with  a  solution  of  glycerin  and 
lemon  juice.  If  the  heart  is  weak,  the  pulse  rapid  and  feeble, 
stimulation  may  be  called  for  by  the  administration  hypoder- 
mically  of  strychnin  sulphate,  %o  grain  (0.00216  Gm.),  every 
three  hours.  Tincture  strophanthus  or  tincture  digitalis  may 
also  be  given  every  three  hours.  Where  rapid  stimulation  is 
desired,  a  hypodermic  of  camphor,  2  grains  (0.130  Gm.)  in  olive 
oil,  may  be  given.  If  the  pain  is  severe  following  operative  in- 
terference, the  use  of  morphin  is  indicated.  After  the  first 
twenty-four  or  thirty-six  hours  following  operation,  the  gen- 
eral condition  of  the  patient  should  be  materially  improved. 
Continued  alarming  symptoms  after  continuous  enteroclysis, 
gastric  lavage,  and  proper  drainage  through  the  abdominal 
wound,  indicate  an  extension  of  the  infection  to  the  general 
blood-stream,  resulting  in  blood-poisoning  or  septicemia. 
Should  the  patient  feel  much  relieved,  however,  if  the  tempera- 
ture has  declined,  and  the  abdominal  drain  is  filtering  the  toxic 
products  of  the  abdomen,  as  shown  by  moist  and  foul-smelling 
dressings,  and  if  the  nausea  has  ceased,  feeding  by  mouth  may 
be  commenced.  Albumin  water,  liquid  peptonoids,  skimmed 
milk,  beef  broths,  and  orange  juice  may  be  given  in  divided 
portions-    Sometimes  rectal  feeding  must  be  resorted  to  if  the 


944  DISEASES    OF   THE   PERITONEUM. 

Stomach  remains  irritable.  An  appropriate  rectal  feeding  may 
consist  of  the  yolk  of  one  egg,  1  tablespoonful  (15  mils)  of 
liquid  peptonoids,  1  tablespoonful  (15  milsj  of  whiskey,  and  4 
ounces  (120  milsj  of  peptonized  milk,  administered  twice  daily 
during  the  intervals  of  enteroclysis. 

Regarding  the  administration  of  raw  eggs,  recent  experi- 
ments have  contradicted  our  usual  opinion  on  this  subject. 
Bateman-  cites  numerous  instances  to  show  that  raw  eggs  may 
cause  diarrhea  and  vomiting,  and  that  the  utilization  of  egg 
white  protein  in  the  alimentarv  tract  is  often  found  to  be  as 
low  as  50  per  cent.  If  this  be  true  of  the  normal  digestive 
tract,  it  is  reasonable  to  suppose  that  the  stomach  and  intes- 
tines, already  hampered  by  an  inflammatory  process,  will  only 
be  able  to  take  care  of  a  much  smaller  percentage  of  egg 
protein. 

Position  of  Patient  During  Acute  Attack  of  Peritonitis.  ]\Ien- 
tion  has  already  been  made  of  the  posture  of  patients  suffering 
from  acute  inflammation  of  the  peritoneal  cavity.  The  mesen- 
teric and  diaphragmatic  portions  of  the  peritoneum  are  the 
areas  most  actively  engaged  in  absorption,  while  the  pelvic 
peritoneum  is  least  active.  The  patient  should,  therefore,  be 
placed  in  such  position  as  will  cause  the  exudations  in  the  peri- 
toneal cavity  to  gravitate  to  the  most  dependent  parts,  where 
absorption  is  very  slow,  prohibiting  the  extension  of  the  in- 
flammatory process.  Fowler  has  recommended  a  semi-recum- 
bent position,  midway  between  sitting  up  and  lying  down. 
This  has  become  a  recognized  method  of  treatment  in  acute  ab- 
dominal conditions,  and  is  known  as  "Fowler's  position."  Even 
before  operation  the  patient  may  be  placed  in  this  posture,  and 
when  moved  from  the  ward  to  the  operating-room.  A  prone 
position. is  only  adopted  after  the  acute  inflammator}^  process 
has  subsided. 

When  to  Stop  Enteroclysis.  The  abdomen  is  capable  of  ab- 
sorbing 10  per  cent,  of  the  body-weight  in  thirty  minutes,  ac- 
cording to  Robinson.  Onh^  sufficient  normal  solution  is  re- 
quired during  the  process  of  enteroclysis  to  wash  out  the  ab- 
domen, to  dilute  the  toxins,  to  allay  thirst,  and  to  activate  the 
kidneys.  AVhere  the  infection  is  severe,  however,  a  large  quan- 
tity of  solution  may  be  necessar^^  AMien  distress  folloAvs  en- 
teroclysis, it  is  due  either  to  rapid  administration,  to  distention 


CHRONIC    PERITONITIS.  945 

of  the  rectum,  or  to  high  pressure  from  the  fountain  syringe 
preventing  the  regurgitation  of  flatus  or  rectal  contents.  When 
the  abdominal  dressings  and  drains  become  moist,  without 
much  staining  and  with  little  or  no  odor,  when  the  pulse  be- 
comes full,  regular  and  strong,  and  when  the  temperature  is 
declining  toward  normal,  it  is  safe  to  assume  that  enteroclysis 
has  already  performed  its  usefulness. 

When  to  Give  Cathartics.  Constipation  is  frequently  present 
during  acute  peritonitis.  This  results  from  a  "splinting"  of  the 
bowel,  which  is  Nature's  method  of  preventing  the  spread  of 
infection.  Just  prior  to  operation  the  rectum  may  be  emptied 
by  an  enema  consisting  of  ^  pint  (236  mils)  of  salt  solution. 
After  operative  interference  the  bowels  are  in  a  state  of  stasis, 
and  peristalsis  is  very  inactive.  The  generation  of  gases  in 
the  intestines  results,  and  is  attended  with  abdominal  disten- 
tion. The  distress  following  the  accumulation  of  gases  is  oft- 
times  ver}^  annoying-.  Relief  may  be  obtained  by  the  insertion 
of  a  rectal  tube  and  by  the  hypodermic  administration  of 
eserin  sulphate,  %o  g^rain  (0.00108  Gm.),  every  three  hours. 
Abdominal  distention  may  also  be  relieved  by  an  asafetida 
enema.  On  the  third  or  fourth  day  following  operation  a  dose 
of  castor  oil  may  be  given. 

CHRONIC  PERITONITIS. 

General  Considerations.  When  the  abdominal  viscera  is  sub- 
ject to  mildly  inflammatory  disturbances  continued  over  a  long 
period  of  time,  there  is  a  gradual  formation  of  connective  tis- 
sue, which  affects  not  only  the  organs  themselves,  but  the 
adjacent  peritoneum.  In  the  case  of  the  liver,  the  increasing 
fibrous  tissue  which  is  common  in  hepatic  cirrhosis  obstructs 
the  abdominal  circulation  so  as  to  afifect  the  entire  peritoneum, 
which  becomes  thickened  and  opaque. 

An  acute  inflammatory  process  of  the  intestines  or  mesen- 
tery may  subside,  causing  adhesions  to  the  abdominal  wall 
or  the  adjacent  viscera,  which  are  localized  forms  of  chronic 
peritonitis.  The  peritoneal  lining  may  also  become  infected 
with  tuberculosis.  This  is  a  chronic,  slow,  degenerative  in- 
flammation, attended  with  or  without  exudation,  causing  ad- 
hesions and  matting  together  of  the  abdominal  viscera.  Any 
foreign  body  may  set  up  a  slow  inflammatory  process,  causing 

60 


946  DISEASES   OF   THE   PERITONEUM. 

symptoms  of  distress  without  systemic  signs.  A  gauze  sponge 
or  a  hemostat  left  in  the  abdomen  following  operation  may  pro- 
duce an  aseptic  inflammatory  condition,  resulting  in  new  fib- 
rous formation,  which  causes  indefinite,  vague,  and  annoying 
abdominal  symptoms.  The  use  of  chemical  or  antiseptic 
agents  in  abdominal  surgery  may  also  bring  about  an  inflam- 
matory process  in  the  peritoneal  cavity,  resulting  in  the  forma- 
tion of  adhesions  between  the  intestines  and  abdominal  wall. 

Chronic  peritonitis  may  be  local  or  general,  depending  upon 
the  extent  and  degree  of  the  irritating  cause.  Localized  peri- 
tonitis is  usually  the  result  of  an  acute  localized  peritonitis 
which  has  subsided.  The  symptoms  are  ofttimes  vague  and 
indefinite  in  character,  but  produce  very  much  discomfort  and 
misery.  Distress  and  sensations  of  pulling  and  drawing  at 
definitely  located  places  in  the  abdomen  are  the  prominent 
complaints.  The  patient  usually  wanders  from  one  physician 
to  another,  with  little  or  no  relief  from  medical  treatment,  until 
radical  operative  measures  are  adopted. 

The  clinical  pathology-  of  a  localized  peritonitis  is  most 
often  shown  post  mortem,  at  autopsy,  for  it  presents  few,  if  any, 
symptoms  during  life,  and  is  seen  as  fibrous  bands  extending 
between  coils  of  the  intestines  and  as  adherent  strands  between 
the  abdominal  viscera  and  the  abdominal  wall.  In  diffuse  ad- 
hesive peritonitis  the  peritoneal  cavity  is  practically  obliter- 
ated, the  intestines  are  matted  together,  and  adhere  closely  to 
the  mesentery.  It  may  often  be  difficult  to  separate  the  parietal 
from  the  visceral  peritoneum.  This  condition  is  usually  seen 
in  the  dry  form  of  tuberculous  peritonitis.  There  is  also  a 
chronic  form,  in  which  the  peritoneal  lining  is  thickened,  and 
presents  a  white,  opaque,  glistening  surface,  with  more  or  less 
exudation  of  serum.  This  is  usually  found  in  hepatic  cirrhosis 
of  long  duration,  attended  with  an  obstruction  of  the  abdominal 
circulation.  Another  form  of  chronic  inflammation  is  pre- 
sented by  a  thickening  of  the  intestinal  walls  and  mesentery, 
which  are  intimately  matted  together,  and  roll  up  in  a  large 
ball,  situated  between  the  stomach  and  the  colon. 

Tuberculous  peritonitis  probably  is  the  most  important 
from  the  standpoint  of  surgical  treatment.  It  is  always  second- 
ary to  tuberculosis  elsewhere,  as  in  the  fallopian  tubes  and  the 
retroperitoneal  glands,  or  it  is  a  part  of  an  acute  miliary  tuber- 


CHRONIC    PERITONITIS. 


947 


culosis.  In  cases  of  infection. by  the  tubercle  bacillus  alone 
there  is  an  exudation  of  serum  attended  with  abdominal  dis- 
tention, the  degree  of  which  will  depend  upon  the  amount  of 
exudation.  In  mixed  infections,  however,  where  other  micro- 
organisms are  present  in  conjunction  with  the  tubercle  bacil- 
lus, the  inflammatory  process  usually  assumes  the  adhesive 
type,  which  is  due  to  the  activity  of  the  complicating  organ- 


Fig.  2. — Tuberculous  peritonitis.    Surface  of  liver,  stomach,  and 
intestines  studded  with  tubercles. 

isms.  When  the  tuberculous  process  has  its  origin  in  the  in- 
testines, the  infection  nearly  always  is  a  mixed  one,  and  the 
pathologic  changes  consist  of  a  matting  together  of  the  intes- 
tines and  mesentery.  Tubercles  may  or  may  not  be  found  upon 
the  peritoneal  surfaces. 

Localized  peritonitis  may  or  may  not  show  symptoms  about 
Digestive  disorders  arise  from  a  chronic 


the  part  affected. 


948 


DISEASES    OF    THE    PERITONEUM. 


inflammatory  process  in  any  part  of  the  abdomen,  and  may  be 
accompanied  by  numerous  nervous  s^-mptoms  bordering  upon 
neurasthenia.  The  history  oi  a  previous  operation  or  of  a 
former  acute  inflammatory  process  may  help  to  locate  the  seat 
of  the  chronic  trouble.  Adhesions  about  the  appendiceal 
region  may  give  rise  to  dull,  dragging  pains,  attended  with  loss 
of  weight,  irritability,  and  sometimes  mental  depression.   Very 


Fig.  3.— Tuberculous  peritonitis,  showing  extensive  matting  of  intestines. 

often  pain  is  entirely  absent,  and  the  case  remains  obscure  with 
indefinite  and  vague  symptoms.  Physical  signs  may  be  absent 
except  in  post-operative  cases,  where  the  scar  may  assist  in 
locating  the  origin  of  the  trouble. 

In  general  peritonitis  the  symptoms  come  on  gradually. 
The  patient  may  complain  of  either  constipation  or  diarrhea; 
there  is  loss  of  weight,  anemia,  and  distress  over  the  abdomen ; 


CHRONIC    PERITONITIS.  949 

digestive  disturbances  are  frequent;  there  is  loss  of  appetite, 
aversion  for  certain  foods  arises,  and  general  neurastlienic 
symptoms  are  prominent.  Pulmonary,  glandular,  or  bone 
tuberculosis  may  precede  infection  of  the  peritoneum. 

The  abdomen  either  is  distended  by  serous  fluid  or  it  may 
be  scaphoid,  firm  and  stifle,  as  the  result  of  contracted  tissues 
beneath.  Palpation  of  the  abdominal  wall  may  detect  the  mat- 
ted condition  of  the  intestines,  which  simulate  a  tumor  mass. 
Percussion  dullness  depends  upon  the  presence  of  fluid  or  the 
thickening'  of  the  mesentery.  When  fluid  is  present,  the  per- 
cussion dullness  will  vary  with  the  posture  of  the  patient. 
Encapsulated  exudations  may  give  rise  to  dull  areas  in  various 
parts  of  the  abdomen  interposed  by  tympany  of  the  distended 
intestines.  Gradual  distention  of  the  abdomen,  which  is  nearly 
always  caused  by  tuberculosis,  is  attended  with  anemia,  loss 
of  weight,  and  sometimes  with  an  evening  temperature.  It 
occurs  most  frequently  in  the  female,  and  points  to  pelvic 
origin. 

TREATMENT. 

The  prevention  of  adhesions  should  be  given  first  considera- 
tion in  the  treatment  of  local  peritonitis.  Walker-^  and  Fergu- 
son have  described  the  formation  of  adhesions  as  due  to  the 
production  of  fibrin,  which  is  the  foundation  for  fibrous  tissue. 

Adhesions  could  be  prevented,  according  to  their  advanced 
theory,  if  coagulation  of  the  exudate  resulting  in  the  formation 
of  a  fibrinous  mass  is  avoided.  Fibrin  is  formed  by  the  action 
of  thrombin  on  fibrinogen,  which  ordinarily  takes  place  in  shed 
blood.  There  are  two  factors  necessary  for  this  action  to  take 
place :  first,  that  blood  in  the  absence  of  its  calcium  content 
remains  fluid ;  and,  second,  that  there  is  some  undetermined 
substance  in  the  nature  of  a  kinase  which  reactivates  the  in- 
active prothrombin  of  the  circulating  blood  to  form  the  active 
thrombin.  It  is  known  as  fibrin  formation  in  shed  blood  and 
can  be  delayed  indefinitely  by  the  addition  of  citrates  or  oxa- 
lates to  hold  the  calcium.  The  authors  of  this  theory  have 
concluded  that  hypotonic  salt  solutions  do  under  certain  condi- 
tions prevent  peritoneal  adhesion  after  laparotomy,  and  that 
the  best  solution  is  composed  of  sodium  citrate  3  per  cent,  and 
sodium  chlorid  1  per  cent,  for  clean  laparotomies.  It  is  recom- 
mended that  500  to  600  mils  (16.9  to  20.2  f^)  of  this  solution 


950  DISEASES    OF    THE    PERITONEUM. 

be  introduced  into  the  abdominal  cavity.  When  packing  off 
the  intestines,  it  is  advised  to  wet  the  gauze  vv^ith  this  citrate 
solution.  This  theor)^  how^ever,  must  be  thoroughly  tried.  It 
is  mentioned  here  because  of  its  acknowledged  importance. 

The  operator  must  take  ample  precautions  to  prevent  trau- 
matism of  the  peritoneum  and  the  serous  coat  of  the  intestines 
or  other  viscera,  otherwise  the  resulting  adhesions  may  offset 
the  advantages  of  the  local  operation.  An  extra  amount  of 
lymph  is  thrown  out  by  the  abused  tissues,  which  adhere  to 
the  adjacent  structures  for  protection.  When  the  stomach,  in- 
testines or  omentum  are  lifted  out  of  the  abdomen  for  any  pur- 
pose during  operative  procedures,  they  should  be  protected 
from  drying  by  the  application  of  hot  moist  compresses  or  by 
thin  sheets  of  rubber  dam.  Dry  gauze  is  irritating  to  these 
structures  and  stimulates  connective  tissue  formation,  with  re- 
sulting adhesions.  Rough  handling  and  frequent  sponging  of 
the  peritoneum  also  injure  this  delicate  structure,  and  predis- 
pose to  adhesion  formations. 

TREATMENT    OF    LOCAL    CHRONIC    PERITONITIS 
(ADHESIONS). 

A  large  proportion  of  those  suffering  from  chronic  consti- 
pation are  so  affected  because  of  peritoneal  adhesions.  In  a 
great  many  autopsies,  regardless  of  the  cause  of  death,  there 
are  invariably  found  isolated  adhesions  in  the  abdomen  which 
have  been  unsuspected  during  life  and  have  produced  few 
symptoms  or  none  at  all.  AVhen  a  patient  complains  of  vague 
and  indefinite  symptoms  in  a  localized  area  in  the  abdomen, 
there  is  strong  suspicion  of  the  presence  of  adhesions.  AVhen 
these  symptoms  become  distressing  to  the  patient,  there  is  but 
one  measure  of  relief  and  that  is  surgical  interference.  This 
consists  of  breaking  up  the  adhesions  by  stripping  them  from 
the  affected  viscera.  This,  however,  leaves  new  raw  surfaces, 
which  may  form  adhesions  again  if  not  properly  protected  in 
the  course  of  operation.  ]\Iorris4  prevents  the  formation  of  new 
adhesions  by  an  aristol  film  or  by  the  use  of  a  Cargile  mem- 
brane made  from  the  sterilized  peritoneum  of  the  ox.  The 
aristol  film  is  formed  by  sprinkling  aristol  powder  over  the 
denuded  surfaces  from  which  the  adhesions  have  been  sep- 
arated.    The  lymph  is  thereby  incorporated  with  the  aristol 


CHRONIC    PERITONITIS.  951 

and  forms  a  protective  coating  for  the  raw  surfaces.  The 
Cargile  membrane  is  placed  over  the  denuded  surface,  and  by 
natural  cohesion  is  approximated  to  the  raw  areas.  If  this  tis- 
sue does  not  adhere,  it  may  be  held  in  place  by  fine  catgut. 
Absorption  of  this  membrane  takes  place  after  the  surfaces  ex- 
posed by  the  detachment  of  adhesions  are  healed.  Sterile  oil 
has  also  been  advocated  to  prevent  the  formation  of  new  ad- 
hesions. Regardless  of  which  method  is  used,  there  is  always 
danger  of  new  adhesions  forming.  Therefore,  the  surgeon 
should  use  as  little  force  as  possible  in  removing  old  adhesions 
iti  order  to  reduce  the  possibility  of  new  tissue  formation. 

TREATMENT    OF    CHRONIC    GENERAL    PERITONITIS 
WITH    EXUDATION. 

Chronic  peritonitis  with  exudation  of  serum  is  nearly  al- 
ways a  tuberculous  process.  The  treatment  is  surgical,  and 
consists  of  opening  the  abdomen,  removing  the  source  of  infec- 
tion, which  may  be  the  fallopian  tubes,  the  appendix  or  en- 
larged abdominal  glands,  and  mopping  out  the  excess  fluid  in 
the  peritoneal  cavity.  Frequently  no  local  lesion  is  found,  and 
a  mere  laparotomy  together  with  the  removal  of  fluid  is  suffi- 
cient to  cause  a  complete  change  in  the  pathologic  condition  of 
the  peritoneum,  resulting  in  a  more  or  less  permanent  cure. 
About  40  to  50  per  cent,  of  cases  of  serous  peritonitis  are  cured 
by  simple  laparotomy. 

Some  surgeons  irrigate  the  abdominal  cavity  with  salt  solu- 
tion, others  dust  the  peritoneum  with  iodoform,  while  still 
others  make  use  of  iodin  solutions,  or  inject  oxygen  on  the 
assumption  that  this  element  has  a  beneficial  efifect  on  the 
tuberculous  process.  It  is  usually  taught  that  there  is  some 
exciting  factor  in  the  air  which,  when  admitted  to  the  abdom- 
inal cavity,  brings  about  a  complete  cure.  Laplace  explains 
this  on  the  ground  that  a  sevefe  impression  is  made  upon  the 
entire  body  by  the  operative  interference,  as  is  sometimes  the 
case  in  epilepsy,  where  surgical  means  may  bring  about  a  pro- 
found change  in  the  individual,  attended  with  more  or  less  im- 
provement of  the  epileptic  condition.  Mayo^»  claims  that  the 
cure  resulting  from  simple  laparotomy  is  due  to  the  fact  that 
the  withdrawal  of  fluids  from  the  abdomen  permits  the  fal- 
lopian tubes  to  come  in  contact  with  some  neighboring*  part  of 


952  DISEASES    OF   THE    PERITONEUM. 

the  peritoneum,  where  they  become  adherent  and  closed, 
thereby  ceasing-  to  drain  tuberculous  products  into  the  peri- 
toneal cavity.  These  occluded  tubes  may  slowly  develop  into 
abscesses,  which,  predisposing  to  a  general  tuberculosis,  may 
be  a  source  of  danger.  In  all  cases  of  tuberculous  infection  of 
the  peritoneum,  whether  the  local  lesion  is  in  the  tubes,  intes- 
tines, appendix,  or  abdominal  glands,  operation  is  always  per- 
formed without  drainage ;  otherwise  secondary  infection  may 
take  place  with  resulting  fistulse  and  septic  infection.  This 
principle  also  holds  true  of  the  surgical  treatment  of  tuber- 
culosis elsewhere.  The  older  writers  call  attention  to  the 
fact  that  spontaneous  evacuation  of  abscess  of  tuberculous 
origin  gives  better  results  than  incision  with  drainage,  which 
invariably  leads  to  a  mixed  infection  and  a  chronic  unyielding 
process. 

NON-EXUDATIVE  CHRONIC  GENERAL 
PERITONITIS. 

In  cases  where  the  symptoms  of  digestive  disturbances  at- 
tended w^ith  colicky  pain  and  chronic  constipation  are  persist- 
ent and  annoying,  it  is  sometimes  necessary  to  resort  to  oper- 
ative interference  to  remove  the  exciting  cause.  On  opening 
the  abdomen,  inspection  is  made  of  the  various  viscera,  and  if 
adhesions  are  found,  these  must  be  removed  by  stripping  or 
by  resection.  A  constricted  bowel  should  be  released  from  its 
adherent  structures  or  removed  by  complete  resection  of  the 
affected  parts.  Lane  recommends  the  removal  of  a  large  por- 
tion of  the  bowel  in  suitable  cases.  Preceding  the  operative 
interference,  however,  the  patient  may  be  assisted  by  the  ad- 
ministration of  various  liquid  paraffin  preparations.  These 
lubricate  the  bowel,  soften  the  stools,  and  tend  to  relieve  many 
of  the  distressing  symptoms.  ^  Where  there  is  exudation,  the 
internal  administration  of  cathartics  and  diuretics  may  be  of 
value  in  reducing  the  peritoneal  fluid.  Tuberculin  may  also  be 
used  in  increasing  doses,  depending  upon  the  reactions  pre- 
sented by  the  patient  in  cases  of  tubercular  infection.  ]\Iedical 
measures  should  also  be  used  after  operative  interference,  when 
general  hygienic  measures  should  be  advocated.  These  pa- 
tients require  out-door  exercise,  restricted  and  carefully  regu- 
lated habits,  and  plenty  of  fresh,  wholesome,  nourishing  food. 


PELVIC   PERITONITIS.  953 

PELVIC  PERITONITIS. 

Because  of  the  intimate  relation  of  the  peritoneum  to  the 
pelvic  organs,  inflammatory  conditions  arising-  in  the  pelvic 
viscera  may  extend  to  the  lower  peritoneal  cavity,  producing 
a  local  pelvic  peritonitis.  The  viscera  are  so  surrounded  and  so 
protected  by  supporting  ligaments  that  inflammatory  processes 
are  usually  confined  to  the  seat  of  origin.  Very  often  the  pel- 
vic inflammation  has  its  beginning  in  the  uterus  and  extends 
through  the  fallopian  tubes  to  the  peritoneum.  Infection  may, 
however,  travel  by  way  of  the  lymphatics  directly  through  the 
uterine  walls  or  by  way  of  the  venous  sinuses,  which  may  carry 
the  infectious  agents  into  the  general  blood-stream.  Injury  or 
rupture  of  any  of  the  pelvic  viscera,  caused  directly  or  indi- 
rectly, may  bring  about  a  state  of  local  peritonitis.  In  the 
female,  however,  peritoneal  infection  practically  always  has  its 
origin  in  the  uterus. 

Inflammations  of  the  pelvic  organs  which  are  severe  enough 
to  involve  the  peritoneum  must  necessarily  be  accompanied  by 
distinct  pathologic  changes.  If  the  tubes  alone  are  afl^ected,  the 
fimbriae  are  matted  together,  the  tubes  are  closed  and  dis- 
torted, and  may  be  adherent  to  adjacent  structures  by  exuda- 
tion. This  exudate  may  be  large  or  small,  depending  upon  the 
severity  and  extent  of  the  infection  and  the  type  of  micro- 
organism prevailing.  A  rapidly  spreading  process  may  have 
little  or  no  exudate,  while  a  subacute  infection  may  have  an 
abundant  serous  or  seropurulent  exudation.  If  no  abscess  has 
been  formed,  all  the  pelvic  organs  may  be  matted  together  in  an 
irregular  mass  with  purulent  material  in  the  pockets  of  con- 
nective tissue.  In  other  instances  the  cellular  tissues  surround- 
ing the  uterus  may  be  the  seat  of  a  round-cell  infiltration  as 
the  result  of  infection  from  the  cervix.  The  amount  and  char- 
acter of  the  exudate  also  vary  with  the  type  of  infection,  and 
may  be  classified  as  serous,  serofibrinous,  or  purulent. 

Infectious  thrombosis  of  the  veins  following-  labor  or  pre- 
mature birth  may  be  the  cause  of  a  severe  pelvic  inflammation 
extending  from  the  sinuses  of  the  uterus  into  the  veins  of  the 
broad  ligaments  and  ovaries.  Such  an  infection  may  result 
in  a  pelvic  abscess,  may  extend  by  continuity  of  tissue  to  the 
abdominal  peritoneum  causing  a  general  peritonitis,  or  may 


954  DISEASES   OF   THE   PERITONEUM. 


Fig.  4. — Pelvic  peritonitis  (tuberculous).    Abscess  in  cul-de-sac  of 
Douglas.    Bladder  implicated  alone. 


PELVIC    PKKITONITIS.  955 

lead  to  an  infection  of  the  general  blood-stream  producing  sep- 
ticemia. In  the  the  male,  rupture  of  the  bladder  or  a  prostatic 
abscess  may  lead  to  pathologic  changes  with  exudation,  de- 
pending upon  the  severity  of  the  case. 

Pelvic  peritonitis  is  usually  superseded  by  symptoms  refer- 
able to  one  or  more  of  the  pelvic  organs.  Pain  in  the  lower 
abdomen  is  the  cardinal  symptom.  The  patient  usually  takes 
to  bed  because  there  is  difficulty  in  walking,  sitting  down,  or 
pain  on  even  slight  movement.  The  temperature  varies  with 
the  degree  of  infection,  ranging  from  100°  to  105°  (37.8°  to 
40.6°  C).  The  higher  temperatures  are  indicative  of  strepto- 
coccic infection  following  labor  or  abortion,  or  of  rupture  of 
one  of  the  pelvic  organs. 

Every  case  of  pelvic  inflammation  in  the  female  gives  a  his- 
tory either  of  labor,  abortion,  chronic  endometritis,  gonorrhea, 
or  instrumentation.  Inspection  of  the  abdomen  reveals  a  limi- 
tation of  the  respiratory  movements,  more  especially  about  the 
part  affected.  In  severe  cases  the  entire  abdominal  wall  may 
appear  stiffened,  while  the  respiratory  movements  of  the  chest 
are  accelerated  to  compensate  for  the  impaired  abdominal 
wall.  Palpation  reveals  tenderness  in  one  or  both  inguinal 
regions  or  over  the  whole  abdomen ;  even  a  board-like  rigidity 
may  be  found  in  severe  cases.  By  percussion  over  the  tubal 
areas  more  or  less  organized  masses  may  be  outlined  as  dull 
areas  surrounded  by  tympany.  Vaginal  examination  nearly 
always  detects  a  discharge,  the  character  of  which  may  lead  to 
suspicion  of  the  type  of  infection.  Following  labor  or  miscar- 
riage the  usual  signs  of  injury  are  detected.  Tenderness  over 
the  tubes  or  uterus  may  be  intensified  by  a  vagino-abdominal 
palpation.  An  abscess  mass  may  be  outlined  on  either  side 
of  the  abdomen  behind  the  uterus.  Such  a  collection  of  pus 
gives  a  sense  of  firmness  to  the  palpating  finger,  is  more  re- 
sistant to  pressure  than  the  surrounding  tissues,  and  is  very 
tender  to  touch.  Abscesses  may  localize  in  the  cul-de-sac  of 
Douglas,  may  be  situated  high  in  the  pelvis,  or  may  extend 
completely  around  the  uterus.  When  the  abscess  is  large,  fluc- 
tuation is  easily  detected.  An  early  forming  abscess  may  be 
found  by  careful  rectal  examination. 

The  usual  septic  symptoms,  such  as  chills,  fever,  and 
sweat,  are  present  in  pelvic  peritonitis,  attended  with  abscess 


956  DISEASES    OF    THE    PERITONEUM. 

formation.  In  cases  of  septic  thrombosis,  pain,  tender- 
ness, and  fever  may  be  present  without  evidences  of  localized 
lesions. 

The  diagnosis  of  pelvic  peritonitis  must  be  differentiated  from 
that  of  acute  appendicitis,  tubal  pregnancy,  acute  endometritis, 
a  tum.or  mass  or  cyst  twisted  on  its  pedicle,  infected  dermoid 
cysts,  and  necrotic  fibroids. 

Appendicitis  usually  gives  the  histor}^  of  digestive  disturb- 
ances, while  pelvic  inflammation  presents  S3'mptoms  referable 
to  the  uterus  accompanied  by  metrorrhagia,  dysmenorrhea,  and 
vaginal  discharge.  An  inflammatory^  process  in  the  lower  ab- 
domen confined  to  the  right  side,  occurring  in  girls  and  un- 
married women,  is  usually  indicative  of  appendicitis. 

In  tubal  pregnancy  there  is  usually  a  history  of  long  sterility, 
cessation  of  menstruation  which  had  previoush'  been  regular, 
sudden  onset  of  pain,  and  persistent  bloody  discharge  from  the 
vagina  for  one  or  two  weeks ;  the  fever  may  be  slight  or  even 
absent,  and  other  signs  of  pregnane}'  are  present. 

Cases  of  pedunculated  pelvic  tumors,  gangrenous  as  the  re- 
sult of  twisting  or  torsion,  may  give  rise  to  a  condition  resemb- 
ling pelvic  peritonitis.  In  the  former,  however,  a  history  of 
tumor  growth  of  gradual  formation  is  obtained.  The  pain 
comes  on  suddenly  with  no  premonitory  symptoms.  Severe 
shock  takes  place  immediately.  Later  there  may  be  fever  re- 
sulting from  the  degenerative  process  in  the  tumor  mass, 
caused  by  obstruction  of  its  blood-supply.  The  absence  of 
other  clinical  symptoms  especially  referable  to  the  uterus  and 
its  appendages  should  be  considered  among  the  diagnostic 
points. 

A  suppurating  dermoid  cyst  may  bring  about  a  local  peri- 
tonitis. The  absence  of  uterine  infection  in  a  woman  who  has 
never  been  pregnant,  presenting  symptoms  of  a  growing  tumor 
in  the  ovarian  region,  should  lead  to  the  suspicion  of  dermoid 
cyst. 

A  fibroid  tumor  undergoing  degenerative  change  may  also 
simulate  a  peritoneal  inflammation,  but  is  distinguished  by  its 
characteristic  symptoms — mainly,  menorrhagia,  leucorrhea. 
pressure-symptoms,  local  pain,  and  a  growth  increasing  in  size 
in  the  lower  abdomen. 


PELVIC    PERITONITIS.  957 


TREATMENT    OF    PELVIC    PERITONITIS. 

When  a  peritoneal  inflammation  is  confined  to  the  region  of 
the  affected  organ,  the  treatment  is  limited  to  a  localized  seat 
of  origin.  Each  case  must  be  treated  according  to  the  type  and 
extent  of  the  lesion  present.  General  measures  which  apply  to 
all  forms  of  regional  pelvic  peritonitis  may  be  enumerated  as 
follows :  Rest  in  bed,  the  use  of  laxatives  as  indicated  in  the 
individual  case,  and  hot  douches  to  lessen  the  amount  of 
vaginal  discharge  and  inflammatory  process  by  stimulating  the 
blood-vessels  and  lymphatics.  -  In  the  case  of  the  old  and  feeble 
and  in  the  young,  heat  may  be  applied  to  the  part  with  great 
relief,  while  in  the  robust  and  in  cases  of  violent  and  rapidly 
spreading  infections  cold  is  advisable.  The  choice  of  heat  and 
cold  rests  with  the  individual  case ;  whichever  gives  the  greater 
comfort  and  relief  should  be  used.  If  the  temperature  is  high, 
an  alcohol  sponge  or  a  warm-water  sponge  may  bring  about  an 
appreciable  decrease.  The  use  of  sedatives  should  be  held 
in  abeyance  unless  operative  interference  has  been  decided 
upon.  Opiates  or  other  sedatives  mask  the  true  diagnostic 
symptoms  of  the  disease,  and  tend  to  mislead  the  surgeon 
in  choosing  the  time  for  operation.  When  pelvic  peritonitis 
follows  labor  or  abortion,  this  is  an  indication  of  infection 
by  reason  of  retained  fragments  of  the  after-birth  or  care- 
lessness in  aseptic  precautions  in  handling  the  patient.  The 
treatment  of  such  cases  should  be  directed  toward  cleaning  the 
uterus  of  its  infected  products,  either  by  the  finger  or  the  curet. 
Any  accumulation  of  pus  in  the  cul-de-sac  of  Douglas  calls  for 
evacuation  by  incision  through  the  posterior  vaginal  wall. 
Drainage  should  be  established  by  the  introduction  of  a  large 
stout  drainage  tube,  which  is  held  in  place  by  packing  with 
sterile  gauze.  The  entire  vagina  is  also  filled  with  sterile  gauze 
to  collect  the  discharging  pus.  This  vaginal  packing  is  re- 
moved daily,  while  the  drainage  tube  is  allowed  to  remain 
until  granulation  has  obliterated  the  abscess  cavity.  Irrigation 
of  the  abscess  is  not  only  unnecessary,  but  may  be  a  dangerous 
procedure  should  the  retaining  walls  of  the  abscess  give  way 
under  the  pressure  of  the  irrigating  fluid,  and  thus  infect  the 
abdominal  cavity. 


"958  DISEASES    OF   THE   PERITOXEUM. 

AA  hen  the  abscess  mass  is  detected  high  in  the  pelvis,  and 
the  inflammaton-  process  is  not  fulminating,  it  mav  be  advis- 
able to  wait  until  the  acute  ?}'mptoms  subside,  provided  that 
the  physical  condition  of  the  patient  is  good.  Pelvic  conditions 
frequently  take  care  of  themselves  during  the  acute  stage, 
localizing  the  infection.  Avlien  conditions  become  more  favor- 
able for  operative  interference.  It  should  be  remembered, 
however,  that  violent,  acute,  fulminant,  and  highly  toxic  in- 
flammations are  dangerous  to  the  life  of  the  patient,  and  that 
waiting  for  these  symptoms  to  subside  may  be  disastrous. 
Immediate  surgical  interference  should,  therefore,  be  adopted 
in  such  cases.  A'er\-  often  mild  infectious  processes  of  the  pel- 
vis undergo  resolution  by  ordinan.-  general  measures,  which 
consist  of  douching,  curetment,  rest  in  bed.  and  the  use  of  laxa- 
tives. Following  the  subsidence  of  the  early  acute  symptoms, 
surgical  interference  may  be  adopted  to  relieve  the  local  infec- 
tion. When  the  inflammators^  process  spreads  rapidly,  the 
peritoneal  cavitv^  must  be  opened  immediately,  either  bv  a 
vaginal  or  abdominal  section.  If  the  former  method  be  chosen, 
the  posterior  Avail  of  the  vagina  is  incised,  the  peritoneal  cavitv 
opened,  and  a  drainage  tube  inserted  and  held  in  place  by  suit- 
able packing.  The  drainage  tube  is  not  removed  until  the 
purulent  discharge  ceases  and  the  acute  inflammaton,?-  symp- 
toms have  subsided. 

Abdominal  section  in  the  median  line  also  may  be  per- 
formed in  extensive  inflammatory  conditions  of  the  pelvis. 
This  procedure  is  adopted  when  the  peritoneal  infection  has 
extended  from  the  pelvis  and  invaded  the  abdomen.  This  per- 
mits the  surgeon  to  reach  pockets  containing  infectious  ma- 
terial not  readih-  drained  through  the  vaginal  incision.  AVhere 
the  iniiammator}'-  process  is  extensive,  it  may  be  advisable  to 
make  a  vaginal  incision  in  addition  to  the  abdominal  opening. 

The  other  measures  following  drainage  in  pelvic  peritonitis 
are  similar  to  those  already  mentioned  under  acute  general 
peritonitis,  which  consist  of  limiting  the  infectious  process 
by  discouraging  peristalsis,  accomplished  by  withholding  food 
and  drink ;  of  the  elimination  of  infectious  material  bv  entero- 
clysis ;  and  of  limiting  the  absorption  of  toxic  products  by 
resorting  to  Fowler's  position  and  gastric  lavage  (q.v.). 

There  are  many  cases  of  pelvic  peritonitis  following  labor 


APPENDICULAR    PERITOXITIS.  959 

and  abortion  which  are  treated  medicinally  with  complete  re- 
covery. Adhesions  may  occur  about  the  inflammatory  parts, 
but  in  spite  of  these  complications  complete  recovery  is  often 
regained.  This  does  not  hold  true  of  gonorrheal  infections, 
which  may  cause  chronic  pelvic  inflammation,  sterility,  and 
chronic  invalidism.  Repeated  attacks  of  pelvic  peritonitis  may 
arise  from  foci  of  chronic  infection  which  become  active  from 
time  to  time  in  the  pelvis,  attended  with  menstrual  disturb- 
ances and  pain  on  exertion.  Surgical  interference  is  usually  in- 
dicated to  prevent  the  recurrence  of  these  attacks. 

APPENDICULAR  PERITONITIS. 

Inflammatory  lesions  of  the  appendix  afifecting  its  entire 
structure  are  practically  always  associated  with  a  local  peri- 
tonitis. The  degree  of  peritoneal  inflammation  depends  upon 
the  severity  of  the  appendiceal  infection,  the  type  of  the  infect- 
ing micro-organism,  and  the  resistance  of  the  patient.  Being 
a  localized  condition,  it  is  reasonable  to  suppose  that  the  peri- 
toneum in  the  immediate  vicinity  of  the  appendix  has  throwm 
out  sufficient  exudate  to  limit  the  inflammatory  process.  The 
pathologic  findings,  therefore,  are  those  of  a  severe  appendicitis 
together  with  more  or  less  exudation  of  serum,  fibrin  or  pus, 
depending  upon  the  stage  of  the  inflammation.  The  appendix 
may  be  either  free  or  bound  down  to  the  adjacent  tissues  bv 
exudate,  it  may  be  hidden  in  an  abscess  mass,  or  separated  from 
its  base  as  the  result  of  a  gangrenous  process. 

The  peritoneal  implication  always  is  dependent  upon  an 
antecedent  inflammation  of  the  appendix.  A  repeated  mild 
catarrhal  inflammation  of  the  appendix  may  lead  to  extension 
of  the  inflammatory^  process  to  the  peritoneum.  It  is  neces- 
sary, however,  that  the  infection  be  of  a  severe  or  moderate 
type  in  order  to  reach  the  peritoneal  cavity. 

The  symptoms  of  appendicular  peritonitis  are  those  of  acute 
appendicitis  together  with  those  of  a  local  peritonitis.  There 
is  pain,  tenderness,  and  rigidity  over  and  surrounding  the  ap- 
pendiceal area.  Fever  is  high,  ranging  from  102°  to  105°  F. 
(38.9°  to  40.6°  C),  and  a  localized  lesion  may  be  palpated 
through  the  abdominal  wall.  There  are  instances  in  which  no 
localized  mass  can  be  detected,  but  there  is  rigidity,  redness. 


960  DISEASES    OF   THE    PERITONEUM. 

and  tenderness,  centered  about  McBurney's  point,  or  at  the  in- 
tersection of  a  line  drawn  from  the  navel  to  the  antero-superior 
spine  of  the  ileum,  with  a  second  line  vertically  placed  cor- 
responding to  the  outer  edge  of  the  right  rectus  muscle. 

There  is  a  high  leucocytosis  ranging  from  twelve  thousand 
to  fifteen  thousand  cells  to  the  cubic  millimeter.  The  resist- 
ance of  the  patient  must  be  great  enough  in  appendiceal  peri- 
tonitis to  localize  the  infection.  This  would  infer  that  phago- 
cytosis has  been  sufficiently  active  to  produce  an  increased  leu- 
cocyte count.  More  especially  is  this  true  in  cases  of  abscess 
formation.  The  diagnosis  of  peritonitis  circumscribed  to  the 
appendix  is  made  upon  the  severity  of  the  localized  symptoms 
of  severe  pain,  tenderness,  rigidity,  abdominal  distention,  and 
upon  the  constitutional  signs  such  as  fever  and  more  or  less 
prostration. 

The  treatment  should  be  directed  toward  the  original  seat  of 
infection,  the  appendix.  Operative  interference  is  practically 
always  indicated,  and  the  earlier  it  is  performed  the  better  the 
prognosis.  In  the  large  majority  of  cases  the  appendix  should 
be  removed,  but  where  there  is  danger  of  disseminating  infec- 
.  tion  or  where  the  tip  of  the  appendix  is  sloughed  away,  it  is 
better  to  resort  to  simple  drainage.  The  abscess  should  be 
thoroughly  cleaned  out,  and  adequate  drainage  provided  for 
by  the  use  of  gauze  packing  and  drainage  tubes.  Other  meas- 
ures of  elimination,  such  as  the  "Murphy  enteroctysis"  and 
gastric  lavage,  should  be  used  as  the  individual  requires.  (See 
p.  767.)  The  treatment  of  appendiceal  peritonitis  by  medical 
means  is  no  longer  advocated.  Although  many  cases  of  mild 
appendicitis  recover  after  the  application  of  heat  or  cold,  rest 
in  bed,  and  the  withholding  of  food,  these  are  but  few  as  com- 
pared with  those  which  sooner  or  later  require  immediate 
surgical  interference. 

SUBPHRENIC  ABSCESS. 

When  one  of  the  abdominal  viscera  is  subject  to  an  acute 
inflammatory  process  attended  with  leakage  of  its  contents  into 
the  abdominal  cavit}^,  an  abscess  may  form,  which  by  process 
of  least  resistance  centers  itself  beneath  the  diaphragm,  and  is 
known  as  a  subphrenic  abscess.  By  far  the  most  frequent 
cause  of  such  phlegmonous  accumulations  is  ulcer  of  the  stom- 


SUBPHRENIC    ABSCESS.  961 

ach,  which,  allowing  the  gastric  contents  to  reach  the  peri- 
toneal cavity,  brings  about  a  purulent  infection  beneath  the 
diaphragm.  A  suppurating  appendix  or  a  duodenal  ulcer  also 
may  be  the  source  of  origin  of  such  an  abscess.  Among  other 
causes  may  be  mentioned  inflammatory  conditions  of  the  bil- 
iary passages,  spleen,  pancreas,  kidney,  liver,  vertebrae,  and 
pleura. 


Fig.  5. — Subplirenic  abscess  originating  in  the  liver. 

The  symptoms  vary  according  to  the  direction  of  the  abscess 
formation  and  the  source  of  its  origin.  When  caused  by  a  per- 
forating gastric  ulcer,  the  symptoms  arise  gradually,  the  infec- 
tion being  confined  by  adhesions  previously  formed  from  the 
gastric  erosion.  There  is  tenderness  in  the  upper  belly  in  the 
right  or  left  hypochondriac  region,  with  a  gradual  bulging  be- 
neath the  ribs  on  either  side.  The  rupture  of  a  newly  formed 
gastric  or  duodenal  ulcer,  with  few  limiting  adhesions,  or  the 

61 


962  DISEASES    OF   THE    PERITONEUM. 

acute  perforation  of  a  purulent  inflammatory  process  in  any  of 
the  other  abdominal  viscera  adjacent  to  the  diaphragm,  pre- 
sents acute  symptoms  characterized  by  rapid  rise  of  tempera- 
ture, pain  or  tenderness  in  the  upper  abdomen,  and  nausea,  and 
vomiting,  consisting  of  stomach  contents,  bile,  or  blood. 

Subphrenic  abscess  usually  presents  a  hectic  type  of  tem- 
perature, attended  with  chills,  sweats,  and  rapid  loss  of  weight. 
An  accumulation  of  pus  pushes  the  diaphragm  upward,  and 
thereby  hinders  the  respiratory  movements.  The  cardiac 
action  is  also  quickened  by  pressure  of  the  abscess  and  by 
stimulation  of  the  toxic  process.  The  inflammatory  process 
may  extend  through  the  diaphragm  into  the  pleural  cavity,  or 
may  even  rupture  into  the  lung,  attended  with  expectoration 
of  pus  and  blood. 

On  palpation  the  lower  border  of  the  liver  is  found  to  be 
depressed,  and  far  below  its  usual  anatomic  line.  On  percus- 
sion, hepatic  dullness  is  found  to  extend  upwards,  and  varies 
with  the  posture  of  the  patient.  Sometimes  tympany  is  elicited 
over  the  bulging  mass,  which  is  due  to  direct  communication 
with  the  stomach  or  to  the  generation  of  gas  produced  by  the 
activity  of  the  colon  bacillus.  The  characteristic  findings  of 
subphrenic  abscess,  therefore,  are,  from  below  upwards,  dull- 
ness over  the  liver,  flatness  over  the  purulent  exudate,  and  tym- 
pany superimposed.  The  compressed  lung  gives  evidences  of 
hyperresonance  and  accentuated  breath-sounds.  Respiratory 
movements  of  the  opposite  lung  are  exaggerated  to  compen- 
sate for  the  side  restricted  by  pressure  of  the  subphrenic 
abscess. 

Differential  diagnosis  must  be  made  between  this  disease  and 
pleural  empyema.  The  latter  condition  points  to  an  antecedent 
history  of  pulmonary  disease  attended  with  dyspnea,  cough, 
and  expectoration,  while  in  the  former  the  symptoms  are 
referable  to  one  or  more  of  the  abdominal  regions. 

Pyopneum.otkorax  may  also  simulate  a  subphrenic  abscess 
with  gas  formation.  The  thoracic  condition  is  accompanied  by 
acute  symptoms  limited  to  the  area  above  the  diaphragm.  In 
subphrenic  abscess,  however,  the  predominant  symptoms  are 
localized  below  the  diaphragm. 

Abscesses  in  the  upper  abdomen  do  not  necessarily  remain 
localized.    They  burrow  in  the  direction  of  the  least  resistance 


PERITONEAL   NEOPLASMS.  '        963 

and  may  point  in  areas  distant  from  the  seat  of  origin,  and 
make  themselves  mostly  conspicuous  in  areas  such  as  the  iliac 
fossa  and  the  retroperitoneal  spaces  of  the  abdomen. 

TREATMENT. 

The  treatment  of  subphrenic  abscess  is  surgical.  A  free  in- 
cision is  made  over  the  most  prominent  part  of  the  abscess  and 
free  drainage  is  established.  By  far  the  largest  number  of 
cures  is  obtained  by  free  and  active  drainage  of  the  abscess 
cavity.  Lang*^  reports  47.9  per  cent,  of  cures  by  surgical  inter- 
ference, and  only  12.3  per  cent,  without  operation.  The  ab- 
scess may  be  opened  either  through  the  abdomen  or  through 
the  chest.  If  by  the  latter  route,  the  pleura  cavity  must  be  pro- 
tected from  infection  by  suitable  packing  or  by  suturing  the 
divided  pleura  to  the  sides  of  the  bulging  abscess  before  in- 
cision is  made.  After  sufficient  drainage,  and  after  the 
pyogenic  cavity  has  been  filled  by  granulations,  attention 
should  be  paid  to  those  causative  factors  responsible  for  the 
abscess,  such  as  ulcer  of  the  stomach,  ulcer  of  the  duodenum, 
or  inflamed  appendix. 

PERITONEAL  NEOPLASMS. 

Tumors  of  the  peritoneum  may  be  primary  or  secondary. 
More  frequently,  however,  the  latter  condition  holds  true,  and 
is  due  to  extension  of  the  neoplastic  growth  from  adjacent  vis- 
cera or  from  distant  sources  through  the  lymphatics. 

The  benign  groivths  usually  have  their  origin  in  the  subperi- 
toneal tissues.  Lipomata  are  either  retroperitoneal  or  may  de- 
velop from  an  epiploic  appendix.  These  are  prone  to  either 
calcareous  or  myxomatous  degenerative  changes.  Fatty  tum- 
ors, when  they  occur  in  the  abdominal  wall,  may  grow  to  a 
fairly  large  size,  pushing  the  peritoneum  forward. 

Fibromata  may  be  found  on  the  parietal  or  visceral  peri- 
toneum and  usually  are  small  in  size. 

Cysts  of  the  peritoneum  may  have  their  origin  in  tumors 
which  have  undergone  mucoid  or  colloid  degeneration.  The 
tubes  and  ovaries  are  the  most  frequent  site  of  cysts  which 
push  the  peritoneum  forward.  Ch^dous  cysts  may  also  be 
found  in  the  peritoneum,  and  appear  as  pedunculated,  grape- 
like, small  or  large  masses  resembling  little  bladders.     Thev 


964  DISEASES   OF  THE   PERITONEUM. 


Fig.  6. — Retroperitoneal  carcinomatous  node  in  the  upper 
abdomen  close  to  the  aorta. 


PERITONEAL    NEOPLASMS. 


965 


are  the  result  of  obstruction  of  the  lymphatic  vessels.  Among 
other  benign  tumors  of  the  peritoneum  are  lymphangioma  and 
chylangioma.  Ecchinococcus  cysts  also  are  found  on  rare 
occasions  in  the  peritoneum. 

The  symptoms  indicative  of  benign  peritoneal  tumors  are 
those  of  pressure,  interfering  with  the  intestinal  movements, 
with  the  circulation,  or  with  both.  The  size  and  location  of  the 


Fig.  7. — Carcinomatosis.    Liver,  stomach,  and  peritoneum  implicated. 


new  growth  especially  influences  and  characterizes  the  nature 
of  the  symptoms.  Digestive  disturbances,  such  as  nausea, 
vomiting,  and  constipation,  vary  with  the  degr&e  of  pressure 
upon  the  intestines.  Stasis  of  the  blood  supply  accompanied 
with  ascites  also  is  dependent  upon  the  degree  of  pressure  and 
the  size  of  the  tumor  mass.  Alany  of  these  growths  of  a  small 
size  are  diagnosed  only  after  laparotomy. 


966  DISEASES    OF   THE    PERITONEUM. 

The  treatment  of  these  growths  is  surgical,  and  calls  for 
removal  when  the  pressure-symptoms  are  severe. 

Among  the  malignant  tumors  are  endothelioma,  carcinoma, 
and  sarcoma.  The  first  of  these  is  primary  in  the  omentum 
wall.  Carcinoma  is  nearly  always  secondary  to  extension  from 
the  adjacent  viscera  or  other  parts  of  the  body.  The  frequent 
sites  of  origin  of  cancer  are  the  stomach,  liver,  gall-bladder, 
uterus,  rectum,  and  breasts.  Cancer  of  the  peritoneum  also 
may  exist  as  nodular  masses  resembling  tubercles  about  the 
abdominal  aorta.  They  are  distinguished  from  tuberculous 
tubercles  by  their  firm  and  dense  structure,  and  they  do  not 
caseate. 

The  entire  abdomen  may  be  affected  with  carcinoma,  this 
condition  being  known  as  carcinomatous.  In  this  disease  the 
omentum  is  retracted,  and  may  appear  as  a  tumor  mass  the  size 
of  a  man's  hand.  Here  and  there  in  the  reduplications  of  the 
peritoneum  on  the  gastrosplenic,  gastrocolic  omentum,  and 
mesentery  are  multiple  cancerous  nodules.  The  surface  of  the 
liver  may  be  sprinkled  with  smaller  nodules  resembling  the 
icing  on  cakes.  Digestive  disturbances,  loss  of  weight,  and  a 
cachectic  appearance,  all  may  lead  to  the  suspicion  of  the  dis- 
ease. Tuberculosis  may  simulate  this  condition,  but  has  in 
addition  to  the  other  symptoms  a  hectic  temperature  and  the 
usual  signs  of  the  disease  elsewhere.  Sarcoma  may  also  afifect 
the  peritoneum.  A  diagnosis  is  usually  made  after  laparotomy 
or  at  autopsy. 

The  treatment  is  symptomatic,  and  should  be  aimed  toward 
relieving  the  patient  and  making  him  comfortable.  Removal 
of  the  extensive  invasion  is  useless,  for  the  neoplasm  is  sure 
to  recur. 

ASCITES. 

Obstruction  of  the  normal  blood  supply  to  the  peritoneum 
results  in  an  accumulation  of  fluid  in  the  abdomen  termed  as- 
cites. This  fluid  is  a  transudation  from  the  blood  through  the 
peritoneal  lining,  and  is  of  a  light  yellow  color,  and  either 
clear  or  turbid,  depending  upon  the  presence  or  absence  of 
cellular  content,  bile,  or  blood.  It  resembles  very  much  the 
serum  of  blood,  from  which  it  is  derived.  The  peritoneum 
shows  little  or  no  change  when  the  transudate  has  its  origin 


ASCITES.  967 

from  a  non-inflammatory  condition.  In  cases  of  peritonitis  the 
serous  covering  of  the  abdominal  wall  may  be  thickened  and 
opaque.  Tuberculous  peritonitis  with  ascites  has  already  been 
described.  (See  p.  946.)  Mention  is  made  of  a  chylous  ascites, 
which  consists  of  the  milk-white  exudate  resulting  from  the 
obstruction  of  the  thoracic  duct. 

The  accumulation  of  fluid  in  the  abdomen  takes  place  grad- 
ually, and  the  symptoms  must  necessarily  appear  in  like  man- 
ner. A  small  amount  of  fluid  gives  rise  to  few  or  no  symptoms 
aside  from  a  sensation  of  fullness  or  weight  in  the  abdomen ; 
when  the  amount  of  fluid  increases  so  as  to  cause  marked  dis- 
tention of  the  abdomen,  the  symptoms  become  very  prominent. 
The  respirations  are  accelerated  as  a  result  of  pressure  against 
the  diaphragm,  and  there  is  great  discomfort  from  the  sense  of 
weight  in  the  abdomen.  The  patient  complains  of  constipation, 
nausea  and  disturbed  digestion,  and  the  pulse  is  accelerated, 
and  the  cardiac  action  is  quickened  by  the  pressure  of  the  re- 
tained fluid.  Pressure  upon  the  kidneys  and  renal  vessels 
causes  a  passive  congestion  resulting  in  the  presence  of  albu- 
min in  the  urine.  The  abdominal  wall  is  uniformly  rounded 
and  prominent,  its  size  depending,  of  course,  upon  the  amount 
of  fluid  present.  By  changing  the  posture  of  the  patient  there 
is  a  change  in  the  contour  of  the  abdomen  corresponding  to 
the  gravitation  of  fluid  to  the  dependent  parts.  The  skin  is 
stretched  and  shiny,  and  its  veins  may  be  markedly  distended. 
The  umbilicus  is  'pushed  forward  at  the  summit  of  the  ab- 
dominal distention.  The  abdominal  respirations  are  practically 
absent,  while  the  chest  movements  are  accentuated,  as  evi- 
denced by  the  quickened  movements. 

The  presence  of  fluid  is  detected  by  placing  the  palm  of  the 
left  hand  on  one  side  of  the  abdomen  while  the  fingers  of  the 
right  tap  lightly  the  other  side.  A  sense  of  fluid  fluctuation  is 
transmitted  by  the  tapping  fingers  to  the  left  hand.  On  per- 
cussion, a  flat  sound  is  elicited  in  the  flanks,  with  more  or  less 
tympany  in  the  center  of  the  abdomen,  where  the  bowels  have 
been  floated  by  the  underlying  fluid.  Posture,  of  course,  dis- 
places the  area  of  dullness  or  flatness,  while  tympany  is  usu- 
ally found  at  the  superior  surface.  The  diagnosis  rests  upon 
the  detection  of  a  movable  area  of  dullness  coupled  with  a 
history  of  obstruction  of  the  abdominal  circulation. 


968  DISEASES    OF   THE    PERITONEUM. 

A  general  uniform  enlargement  of  the  abdomen  must  not 
be  mistaken  for  an  ovarian  cyst  or  for  a  chronic  peritonitis  fol- 
lowing inflammation  of  the  abdomen,  tuberculosis,  or  diseases 
of  the  female  pelvic  organs.  A  distended  bladder  is  some- 
times confused  wth  localized  ascites.  This  latter  condition 
may  be  eliminated  by  catheterization. 

TREATMENT. 

The  elimination  of  the  fluid  may  be  accomplished  readily 
by  tapping  the  abdomen  or  by  the  use  of  cathartics,  diuretics, 
and  diaphoretics.  It  is  difficult  in  cases  of  obstructed  circula- 
tion to  remove  the  cause,  which  may  be  cirrhosis  of  the  liver 
or  cancerous  growths  impeding  the  portal  circulation.  In 
cases  of  S3^philis  of  the  liver,  however,  treatment  should  be 
directed  toward  relieving  the  systemic  disease.  When  the 
ascites  is  due  to  abscess  of  the  liver,  carcinoma,  cysts  (hyda- 
tid), or  enlarged  glands  these  sources  of  obstruction  should  be 
removed  by  surgical  interference.  Pulmonary  conditions,  such 
as  emphysema  and  cardiac  disease  wnth  insufficiency  of  the 
circulation,  must  be  treated  accordingly.  Bright's  disease  and 
malaria  also  ma}'-  be  causative  factors  of  ascites,  which  must  be 
treated  by  appropriate  measures. 

When  the  distention  of  the  abdomen  is  great,  the  fluid  must 
be  drained  off  by  tapping  or  paracentesis.  This  must  be  re- 
peated as  often  as  is  necessar}^,  more  especially  in  cases  of  cir- 
rhosis of  the  liver,  where  it  may  assist  in  re-establishing  ab- 
dominal circulation.  AVhen  a  small  amount  of  fluid  is  present, 
elimination  may  be  accomplished  by  the  use  of  hydragogue 
cathartics,  more  especially  when  the  condition  is  due  to  car- 
diac or  renal  disease.  Among  the  cathartics  recommended  are 
magnesium  sulphate,  Rochelle  salt,  jalap,  gamboge,  colocynth, 
and  calomel.  Elimination  may  also  be  practised  through  the 
kidneys  by  the  use  of  diuretics  such  as  potassium  citrate, 
spiritus  mindererus,  and  copaiba.  Sweating  ma}^  be  encouraged 
by  the  use  of  hot  drinks,  the  application  of  hot-water  bottles, 
and  plenty  of  warm  covers. 

Some  surgeons  have  attempted  to  assist  the  obstructed  cir- 
culation by  diverting  it  to  other  channels.  Talma  advocates 
the  suturing  of  the  great  omentum  to  the  anterior  abdominal 
wall,  where  a  new  circulation  is  established  which  drains  off 
the  ascites  into  the  systemic  blood-vessels. 


ASCITES. 


969 


Method  of  Tapping  the  Abdomen  for  Ascites.  After  shaving 
and  scrubbing-  the  abdomen,  the  patient  is  placed  in  an  upright 
position  or  in  the  semi-recumbent  posture.  A  point  midway 
between  the  umbilicus  and  pubes  is  selected  for  the  introduction 
of  a  trocar  and  canula;  the  skin  surface  is  painted  with  iodin 


Fig.  8. — Abdominal  paracentesis.  Canula  in  place,  drawing  off 
fluid.  Note  position  of  ungloved  hand  exerting  pressure  on  abdo- 
men to  encourage  flow  of  fluid  into  basin. 


and  anesthetized  by  the  intradermic  injection  of  cocain.  The 
bladder  is  catheterized  before  the  abdomen  is  prepared  for 
operation.  An  incision  is  made  about  y2  inch  (12.7  mm.)  long 
in  the  median  line  at  the  selected  point  through  the  skin  and 
a  firm  thrust  is  made  through  the  abdominal  tissue  with  the 


970  '     DISEASES    OF   THE    PERITONEUM. 

trocar  and  canula.  The  trocar  is  withdrawn  and  the  canula 
depressed  to  drain  oft  the  abdominal  fluids.  Great  care  must 
be  exercised  to  avoid  puncturing-  the  intestines — an  accident 
sometimes  unavoidable  when  the  bowel  is  adherent  to  the  ab- 
dominal wall.  Careful  study  of  the  case  by  percussion  should 
determine  whether  the  intestines  are  free  or  adherent.  Should 
the  intestines  be  accidentally  ruptured,  the  case  should  be 
treated  just  as  any  other  perforating  wound  of  the  abdomen. 
After  the  fluid  has  been  removed  from  the  abdomen,  the  canula 
should  be  withdrawn  and  the  opening  closed  by  gauze  com- 
press and  adhesive  strips. 

BIBLIOGRAPHY. 

1.  Robinson :    The  Peritoneum,  1899,  Ed.  3.  398. 

2.  Bateman :    Amer.  Jour.  Med.  Sci.,  1917,  153,  841. 

3.  AA'alker  and  Ferguson :    Ann.  Surg.,  1916,  Ixiii,  198. 

4.  Morris :     Sajous's  Analytic  Cj^clopedia  of  Practical  Medicine,   1914, 
i,  34. 

5.  Mayo :     Collected  Papers  of  Mayo  Clinic,  1912,  vi,  691. 

6.  Lang:     Keen's  Surgery,  1908,  iii,  869. 


INDEX. 


Abdominal  abscess,  936 

aneurysm,  259,  262 

prognosis,  263 

symptoms,  262 

Abscess,  abdominal,  936 

dental,  in  cardiac  affections,  215 
gastric,  757 
iliac,  849 

of  kidney,  627.     See  Kidney, 
of  liver,  905.     See  Liver, 
periapical,  653 
perigastric,  692 
perinephritic,  632 
etiology,  632 
symptoms,  632 
treatment,  632 
pulmonary,  478 

complicating  pneumonia,  480 
diagnosis,  480,  481 
differentiated     from    gangrene, 

485 
etiology  478 
pathology,  479 
physical  signs,  482 
symptoms,  481 
treatment,  483 
surgical,  483 
subphrenic,  960 

differential  diagnosis,  962 
etiologA^,  960 
symptoms,  961 
treatment,  963 
Absence  of  kidney,   552 
Achylia  gastrica,  762 
Acid,  gastritis,  762 

hippuric,   551 
Acromegaly,   151 
pathology,  151 
symptoms,   152 
treatment,   154 
Actinomycosis,  pulmonary,  493 
diagnosis,  493 
etiology,  493 
pathology,  493 
treatment,  494 
Acute  appendicitis,  850 
bronchitis,  326 
catarrhal  gastritis,  750 
cholangitis,  890 
cholecystitis,  890 
colitis,  845 

dilatation   of   stomach,  818.     See 
Gastrectasis. 


Acute  enteritis,  837 
esophagitis,  674 
fibrinous  pleuritis,  502.    See  Pleu- 

ritis. 
gastrectasis,  818 

gastritis,  750.    See  Gastritis,  757. 
general      peritonitis,      927.        See 

Peritonitis, 
glossitis,  668 
infectious      gastritis,      755.        See 

Gastritis, 
leukemia,  30 
miliary  phthisis,  400 
pancreatitis,  916,  917 
parenchymatous      nephritis,      578. 

See  Nephritis, 
peritonitis,  927.     See  Peritonitis, 
phlegmonous   gastritis,    757.      See 

Gastritis, 
pulmonary    tuberculosis,    general, 

400 
simple    gastritis,    750.      See    Gas- 
tritis, 
suft'ocative  pulmonary  edema,  476 
suppurative  gastritis,  757 
thyroiditis,  107,  108 
yellow  atrophy  of  liver,  908.     See 
Liver. 
Addisonian  anemia,  18,  19,  20,  23 
Addison's  disease,  80 
Adenitis,  tuberculous,  differentiated 
from  Hodgkin's  disease,  45 
Adenoma  of  adrenals,  91 
of  kidney,  639 
of  liver,  913  _ 

Adhesions,  pericardial,  222,  225 
peritoneal,  945,  946 
prevention,  949,  950 
symptoms,  947 
treatment,  949,  950 
Adrenal  extract  in  heart  block,  219 
glands,  67 

adenoma  of,  91 
angioma  of,  91 
antitoxic  function  of,  70 
benign  tumors  of,  91 
symptoms,  91 
treatment,  92 
connections    with    other   glands 

and  organs,  71,  72 
chromaffin  tumors  of,  91 
chromaffin  substance  in,  67 
echinococcic  cvst  of,  91 

(971) 


972 


INDEX. 


Adrenal  glands,  effect  of  removal,  69 
fibroma  of,  91 
function,  69 
ganglioneuroma  of,  91 
histolog}',  67 
hj-pernephroma  of,  90 
lipoma  of,  91 
malignant  tumors  of,  90 
symptoms,  90 
treatment,  91 
paragangliomas  of,  91 
transplantation  of,  81,  82 
tumors,  90 
hematoma,  87 

treatment,  88 
hemorrhage,  85 
hemorrhagic  pseudo-cyst,  87 
insufficiency,    12.      See    Hypoad- 

renia. 
overactivity,  84 
etiolog\%  84 
treatment,  86 
rests,  68,  88 

secretion,    effects    on    blood-pres- 
sure, 70 
physiologic  action  of,  70 
Albumin  in  urine,  tests  for,  570 
quantitative,  571 
reaction  in  sputum,  379 
Albuminometer,  Esbach's,  571 
Albuminuria,  569 
Bence-Jones,  570 
etiology.  569 
febrile,  569 

significance  of,  569 
functional,  570 
significance  of,  569 
tests  for,  570 
quantitative,  571 
Albumosuria,  570 

test  for,  570 
Alcohol  in  heart  diseases,  285 

in  pulmonarv  tuberculosis,  429,  430 
Alcoholic  gastritis,  779 

treatment,  779 
Allen  treatment  for  diabetes,  470 
Alpha  iodin  compound,  95,  97 
Alternation  of  heart,  219 
diagnosis,  220 
etiolog3%  219 
prognosis,  220 
treatment,  221 
Ammonia  as  a  cardiac  drug,  286 
Ammonium  chloride  in  phthisis,  449 
Amyl  nitrite,  283 
Amyloid  casts,  574 

degeneration  of  kidne",  618.     See 

Kidney, 
disease  of  liver,  911 
Anacid  gastritis,  762 


Anacid  gastritis,  treatment,  778,  779 
Anaphylaxis  and  asthma,  352,  354 

and  hay  fever,  359 
Anemia,  Addisonian,  18,  19,  20,  23 
aplastic,  20 
classification  of,  4,  5 
due  to  intestinal  parasites,  6 

to  gastric  cancer,  treatment  of, 
743 

to  pulmonarv  tuberculosis,  382, 
459_ 
general      indications      for     treat- 
ment, 3 
in  chronic  nephritis.  592 
lightning  pains  in,  29 
of  kidney,  574 

etiology',  574 

treatment,  575 
pernicious,     17.      See    Pernicious 

Anemia, 
prim  an,',  4 

splenic,  47.     See  Splenic  Anemia, 
symptomatic  secondary,  4 

due  to  intestinal  parasites,  6 

etiolog}',  5 

pathology-,  5 

symptoms,  6 

treatment,  6 
dietetic,  6 
hygienic,  7 
therapeutic,  7 
Aneurysm,  259 

abdominal,  259,  262 

prognosis,  263 

symptoms,  262 
etiology-,  259 
neosalvarsan  in,  264 
pathology,  259 
rest  in,  264 
salvarsan  in,  263 

stricture  of  esophagus  from,  682 
svmptoms,  261 
thoracic,  259,  261 

cardiac  dilatation  in,  262 

cardiac  hypertrophy  in,  262 

symptoms,  261 
treatment,  263 

of  pain,  265 

Tufnel's,  265 
venesection  in,  265 
wiring  of,  266 
Angina,  Ludwigs,  674 

etiolog3\  674 

symptoms,  674 

treatment,  674 
pectoris,  25S__ 

etiology-,  255,  256 

physical  signs,  257 

prognosis,  257 

symptoms,  255,  256,  257 


INDEX. 


973 


Angina  pectoris,  treatment,  257 

Vincent's,    659.      See    Stomatitis, 
Ulcerative. 
Angioma  of  adrenals,  91 

of  liver,  913 
Anomalies  of  the  kidney,  552 
Anorexia  in  pulmonary  tuberculosis, 

442 
Anthracosis,  486 

Antiforniin  method  of  demonstrat- 
ing tubercle  bacilli,  378 
Antitoxin,  diphtheria,  in  asthmatics, 

354 
Anuria,  561 

differentiated  from  retention,  562 

etiology,  561 

symptoms,  562 

treatment,  562 
Aortic  regurgitation,  253 
etiology,  253 
physical  signs,  253 
prognosis,  248 
sudden  death  in,  248 

stenosis,  254 
symptoms,  254 
Aphthae,  Bedner's,  658 

treatment,  658 
Aphthous      stomatitis,      656.        See 

Stomatitis. 
Aplastic  anemia,  20 
Appendicitis,  849 

acute,  850 

chronic,  850 

differentiated    from    pelvic    peri- 
tonitis, 956 

etiology,  849 

indications  for  operation  in,  851 

peritonitis  in,  959 

symptoms,  850 

treatment,  851 
Appendicular  peritonitis,  959 

pathology,  959 

symptoms,  959 

treatment,  960 
Arhythmias,    classification    of    car- 
diac, 206 

sinus,  207 
Arsenic  in  anemia,  7 

in  chlorosis,  12 

in  Hodgkin's  disease,  47 

in  infantile  splenic  anemia,  51 

in  leukemia,  Zl 

in  pernicious  anemia,  21,  22,  23 

in  purpura,  55 

in  tuberculosis,  459 
Arteriosclerosis,  267 

and  nephritis,  268,  600 

etiology,   267 

hypertrophy  of  heart  in,  268 

pathologic  histology,  268 


Arteriosclerosis,  prognosis,  271 
symptoms,   268 
treatment,  271 
Arteriosclerotic  kidney,  599 
Artery,  pipe-stem,  271 
Arthritic  purpura,  52 
Artificial    pneumothorax     in     bron- 
chiectasis, 348 
in    pulmonary    tuberculosis,    423, 
424,  425,  427 
for  hemoptysis,  455 
Ascites,  966 
diagnosis,  967 
symptoms,  967 
treatment,  968 
Aspergillosis,  pulmonary,  499 
Asthma,  bronchial,  349.     See  Bron- 
chial Asthma, 
cardiac,  476 

hay-,  351,  358.     See  Hay-fever, 
thymic,  140,  142 
treatment,  143 
Atony,  intestinal,  867 

treatment,  869 
Atoxyl,  38 

Atrophic    cirrhosis    of    liver,    898. 
See  Liver, 
emphysema,  362 
gastritis.  761 
Atrophy  of  liver,  acute  yellow,  908. 

See  Liver. 
Atropin  as  a  cardiac  drug,  284 

in  gastric  ulcer,  700 
Auricular    contractions,    premature, 
208 
fibrillation,  212 
etiology,  212 
in  arteriosclerosis,  271 

treatment,  273 
prognosis,  214 
symptoms,  212 
treatment,  214 
flutter,  211 
prognosis,  212 
symptoms,  211 
treatment,  212 
Auriculoventricular  node,  203 
Auscultatory    method    of    determin- 
ing blood-pressure,  275 
Autogenous    vaccines    in    endocar- 
ditis, 241 

Bacelli's  sign,  514 
Bacillary  emulsion  of  Koch.  431 
Bacilli,    colon,    as    cause    of    peri- 
tonitis, 933 
tubercle.  378 

inoculation  test  for,  379 
staining  of,  Zl^ 
Backw^ardness  in  children,  138 


974 


INDEX. 


Backwardness      in      children,      fre- 
quency, 138 
treatment,  139 

with  pineal  extract,  172 
Bacterial  toxins  in  leukemia,  40 
Bacterins    in    treating    diseases    of 
lungs,   bronchi   and  pleura, 

Bacteriology  of  pleural  fluids,  502 
Balneotherapy,  286,  287  ^ 

of  chronic  gastritis,  770 
■Banti's  disease,  48 
Basedow's  disease,  109 
Bathing  in  pulmonary  tuberculosis, 

422,  423,  456,  457 
Baths,  electric  light,  587    • 

hot  air,  587 

Nauheim,  286,  287 
B.  E.,  431 

Bed,  Klondike,  410  _ 
Bednar's  aphthae,  6S8 

treatment,  658 
Belladonna  in  gastric  ulcer,  700 
Bence-Jones  proteinuria,  570 
Benzol  in  leukemia,  35 
Bertini,  columns  of,  544 
Biliary  cirrhosis  of  liver,  898,  899. 

See  Liver. 
Biliousness,  875 

etiology,  875 

symptoms,  875 

treatment,  876 
prophylactic,  876 
Binet-Simon  test,  139 
Bismuth  in  gastric  ulcer,  700 
Blaud  tabloid,  236 
Blastomj^cosis,  pulmonary,  499 
Bleeders,  56 
Bleeding  time,  53 

Blistering     in     pulmonary     tuber- 
culosis, 461 
Blisters,  fever,  649 
Block,  heart-,  216,  243 

etiolog^^  216 

prognosis,  218 

symptoms,  217 

treatment,  218 
Blood,  creatinin  in,  610 

defibrinated,  injections  of,  24 

diseases  of,  3 
classification,  4,  5 

test.  Heller's,  567 

transfusion  in  pernicious  anemia, 
23 

urea  in,  608 

uric  acid  in,  606 
Blood-pressure,  273 

decreased,  277 

factors  maintaining,  275 


Blood-pressure,  importance  of  com- 
parative readings,  276 
increased,  276,  277 

treatment,  277 
instruments,  274 
in  nephritis,  615 
in  tuberculosis,  382 
method  of  determining,  274 

auscultatory',  275 
normal,  270,  276 
Bougie,  esophageal,  683 

technic  of  passing,  683 
Bovine  tuberculosis,  402,  403 
Bowman,  capsule  of,  544 
Breath,  foul,  650  _ 
Breathing,  bronchial,  396 
bronchovesicular,  396 
cog-wheel,  395 
exercises  in  pleuritis,  509 

contraindications,  509 
feeble,  395 
granular,  395 
in  tuberculosis,  395,  396 
tubular,  396 
Breath  sounds  in  tuberculosis,  394, 

395 
Bright's    disease,    578.      See    Neph- 
ritis. 
Bronchi,  bacterin  treatment  of  dis- 
eases of,  534 
Bronchial  asthma,  349 
and  anaphjdaxis,  352,  354 
and  emphysema,  362,  367 
diphtheria  antitoxin  in,  354 
etiology,  349,  353 
pathology,  349 
symptoms,  350 

tests  for  protein  sensitization  in, 
352 
cutaneous,  352 
intracutaneous,  353 
treatment,  351 

between  attacks,  355 
b}^  defibrinated  blood,  355 
b}^  desensitization,  354 
oi  attack,  356 
vaccines  in,  355 
Bronchial  breathing  in  tttberculosis, 
396 
casts,  337,  338,  339 
Bronchiectasis,  339,  473 
etiology,  340 
hemorrhages  in,  342 
pathology,  340 
physical  sIptis,  342 
symptoms,  341 
treatment,  343 

by  artificial  pneumothorax,  348 

by  inhalations,  344 

by  intratracheal  injections,  345 


INDEX. 


975 


Bronchiectasis,    treatment,    climatic, 
349 
postural,  346 
vaccine,  345 
X-ray  diagnosis  of,  343 
Bronchitis,  acute  and  subacute,  326 
etiology,  327 
in  tuberculosis,  447 
pathology,  326 
prophylaxis,  328 
symptoms,  327 
treatment,  328 
abortive,  328 
drugs  in,  330 
hygienic,  330 
inhalations  in,  330 
local  applications  in,  329 
chronic,  332 

and  emphysema,  362,  ZGl 
etiology,  333 
in  tuberculosis,  447 
pathology,  333 
treatment,  ZZZ 
climatic,  335 
drugs  in,  335 
general,  334 
hygienic,  334 

of   associated  primary  condi- 
tion, 334 
tonic,  335 
•  vaccine,  Z2^ 
fibrinous,  337 
etiology,  ZZl 
pathology,  ZZl 
symptoms,  338 
treatment,  339 
in  pulmonary  tuberculosis,  447 
Bronchovesicular    breathing    in    tu- 
berculosis, 396 
Bubbbling  rales  in  tuberculosis,  397 
Bundle  of  His,  203 

Cachectic  purpura,  52 
Caffein  as  a  heart  drug,  285 
Calcification  of  tubercules,  371,  372 
Calcium  oxalate  stones,  619 
Calculi,  pancreatic,  919 

salivary,  673 
Cammidge  reaction,  915 
Camphor,  286 
Cancer,  green,  43 

See  also  Carcinoma. 
Cancrum  oris,  661.     See  Stomatitis, 

Gangrenous. 
Cane  sugar  in  myocarditis,  234 
Capsule  of  Bowman,  544 
Carcinoma,   frequency  of,  724 

lymphatic  and  Hodgkin's  disease, 
45 

of  esophagus,  (:!n .   See  Esophagus, 


Carcinoma  of  intestines,  869,  870 
of  kidney,  639 
of  liver,  913 
of  lungs,  496 
of  pancreas,  921 
of  peritoneum,  966 
of  pleura,  526 
of  tongue,  671 
Cardiac     arhythmias,     classification 
of,  206 
asthma,  476 

compensation,   treatment   of    fail- 
ing, in  nephritis,  614 
cvcle,  204 
drugs,  use  of,  278 
failure,  causes  of,  245 
irregularities,  202 
physiology,  203 
Cardiograms,  205 
Cardiospasm,  810 
diagnosis,  814 
esophagitis  complicating,  812,  816 

treatment,  816 
etiology,  810 
forms  of,  812 
prognosis,  816 
symptoms,  812 
treatment,  816 
Cardiovascular    symptoms    of    pul- 
monary tuberculosis,  382 
Cargile  membrane,  950,  951 
"Carriers"  of  disease,  645,  663 

treatment,  664 
Cathartics   in  acute  peritonitis,   use 

of,  945 
Caseation  in  tuberculosis,  371,  372 
Casts,  572 
amyloid,  574 

significance  of,  574 
bronchial,  ZZ1 ,  338,  339 
epithelial,  573 

significance  of,  573 
fatty,  573 

significance  of,  573 
granular,  573 

significance  of,  573 
hyaline,  573 

significance  of,  572,  573 
leucocytic,   573 

significance  of,  573 
significance  of,  572 
waxy,  574 

significance  of,  575 
Catarrh  of  stomach,  759 
Catarrhal   enteritis,   chronic,  839 
gastritis,  acute,  750 
stomatitis,  655,  656 
Cavity  formation  in  puliuonary  tu- 
berculosis, 372,  397 
Chalicosis,  486 


976 


INDEX. 


Charcot-Lej-den  crystals,  351 
Chest  pains  in  tuberculosis,  383 
percussion  of.  technic,  390 
phthisical,  3S4 
Chloroma,  43 
patholog}',  43 
symptoms,  43 
treatment.  43 
Chlorosarcoma,  43 
Chlorosis.  S 
etiologA".  8 
.    florida,'9 

hA'drotherapy  in,  13 
incidence  of,  9 
massage  in,  13 
patholog}',  8 
rubra,  9 
symptoms,  9 

cardiovascular.  17 
gastro-intestinal,  15 
nervous.  16 
treatment,  10 
dietetic,  14 

of  special  symptoms,  15,  16,  17 
Cholangitis,  acute,  890.     See  Chole- 
cj-stitis. 
chronic,  894 
etiology-,  894 

indications  for  operation,  898  * 
symptoms,  894,  895 
treatment,  895 
Cholecvstitis,  acute.  890 
etiblog}',  890 
limitations  of  medical  treatment 

in.  898 
SA-mptoms,  890 
treatment.   891 
Cholelithiasis.  892 
chronic,  894 
indications  for  operation  in,  897 
symptoms,  894,  895 
treatment.  895 
diasrnosis,  893 
etiolog}-,  892 
limitations    of    medical  treatment 

in,  898 
svmptoms.  892 
treatment,  893 
Cholera  infantum,  844 
prognosis,  844 
SATnptoms.  844 
treatment.   844 
Chorea  in  endocarditis.  241 
Chromaffin  substance,  67,  68 

tumors  of  adrenals.  91 
Chromophiles,  145 
Chromophobes,  145,  152 
Chronic  bronchitis,  332.     See  Bron- 
chitis, 
endocarditis,  237 


Chronic  gastritis,  759.    See  Gastritis. 

leukemia,  30 
Chvostek's  sign,  132 
Chylothorax,  529 
diagnosis,  529 
treatment.  529 
Chyluria,  568 
diagnosis,  568 
etiolog3%  568 
treatment,  568 
Chronic  appendicitis,  850 
cholangitis,  894 
cholelithiasis,  894 
colitis,  845.     See  Colitis, 
endocarditis,  237 
enteritis,  839 
gastritis,  759 
glossitis,  669 

m3'ocarditis,    230.      See    Myocar- 
ditis, 
pancreatitis,  918 

peritonitis,  945.     See  Peritonitis, 
progressive  hj-poadrenia,  80 
etiology-,  80 
patholog3%  80 
symptoms,  80,  81 
treatment,  81 
thyroiditis,  108,  109 
ulcerative  pulmonary  tuberculosis, 
400,  401 
Circulatorv  disturbances  of  kidney, 

574 
Cirrhosis  of  liver,  898.     See  Liver. 
Citrate  of  iron  in  anemia,  12 
Climatic  treatment  of  tuberculosis, 

408 
Clubbed  fingers  in  tuberculosis,  384 
Coagulation  time.  57 
Coefficient  of  Haeser,  547 
Cog-wheel  breathing  in  tuberculosis, 

395 
Coin  test,  532 

Cold  bath  in  tuberculosis,  422 
sores,  649 

sponges  in  tuberculosis,  422,  425, 
457 
Colic,  gall  stone,  893 

renal,  treatment  of,  622 
Colitis,  acute,  845 
sjTuptoms,  845 
treatment,  845 
chronic  mucous,  845 
etiolog}-,  846 
patholog}-,  846 
sex  incidence.  845 
S3-mptoms,  846 
treatment.  847 
ulcerative.  848 
symptoms.  848 
treatment,  848 


INDEX. 


977 


Colitis,  ulcerative-  varieties,  848 
Colloid  goiter,  123 

material  of  thyroid,  92,  93,  97 
Colon  bacilli  as  cause  of  peritonitis, 

933 
Columns  of  Bertini,  544 
Commissures,  rhagades  of,  648 
Compensation,  treatment  of   failing 

cardiac,  in  nephritis,  614 
Compensatory  emphysema,  362,  369 

pathology  of,  369 
Complement  fixation  test  in  tuber- 
culosis, 375 
Congenital    cystic    degeneration    of 
kidney,  639 
goiter,  120,  126 
treatment,  126 
pyloric  stenosis,  804.     See  Pyloric 

Stenosis, 
syphilis  of  liver,  912 
valvular  defects,  249 
Congestion,   pulmonary,  474 
etiology,  474 
pathology,  475 
physical  signs,  475 
symptoms,  475 
treatment,  476 
Constipation,  854 
as  a  functional  neurosis,  868 

treatment,  869 
causes  of,  854 
diet  in,  855 

due  to  diminished  intestinal  sensi- 
bility, 867 
treatment,  869 
due  to   gastric  cancer,  treatment 

of,  745 _ 
in  tuberculosis,  444 

treatment,  446 
treatment,  855 
mechanical,  858 
medical,  857 
Constrictions,     normal     esophageal, 

.  684 
Constrictive  goiter,  123 
Contractions,    premature    auricular, 
208 
premature,  of  heart,  208 
etiology,  208 
treatment,  208 
Corpus  luteum,  function  of,  173 
Cough,  emetic,  378 
in  tuberculosis,  Zll ,  446 
treatment,  446 
Coupling,  digitalis,  214,  282 
Creatinin,  551 
amount,  551 

in  blood,  estimation  of,  610 
origin  of,  551 
tests  for,  551 


Creosote  in  pulmonary  tuberculosis, 

448 
Cretinism,  103 

endemic  type,  104 

sporadic  type,  104 

symptoms,   103,  104 

thyroid  grafting  in,  105 

treatment,  104 

Wenzel's  classification  of,  104 
Cretinoids,  104 

Crises,    gastric,    826.      See    Gastric 
Crises. 

visceral,  826 
Crisis,  Dietl's,  556 
Croupous  gastritis,  756 
Crystals,  Charcot-Leyden,  351 
Cupping,  technic  of  dry,  589 
Cups,  sputum,  405 
Curshmann's  spirals,  351 
Curved    finger   nails    in    pulmonary 

tuberculosis,  384 
Cycle,  cardiac,  204 
Cylindroids,  574 

significance  of,  574 
Cystic  degeneration  of  kidney,  con- 
genital, 639 

goiter,  123 
Cysts  of  liver,  913 

of  pancreas,  920 

of  peritoneum,  963 
Cytology  of  pleural  effusions,  501 

Danger  zone  in  tuberculosis,  397 

zones  of  peritoneum,  929 
Death,  thymic,  140,  142 
Defibrinated  blood,  24,  40 

in  asthma,  355 
Degeneration  of  kidney,  congenital 

cystic,  639 
Dental   abscesses   in   heart   disturb- 
ances, 215 
Desensitization  in  asthma,  354 
Determination  of  degree  of  activity 
of  tuberculosis.  401 

of  degree  of  improA'ement,  401 
Diabetes,  Allen  treatment  for,  470 

and  hyperpituitaria,  150,  162 

complicating  tuberculosis,  470 
Diarrhea,  and  enteritis,  841 

febrile,  841 

inflammatory,  841 

in  pulmonary  tuberculosis,  445 

nervous,  868 
treatment,  869 

summer,  841 
Diet,  in  acute  parenchvmatous  neph- 
ritis, 584 

in  peritonitis,  943 

in  carcinoma  of  stomach.  740 

in  catarrhal  jaundice,  879 


978 


IXDEX. 


Diet  in  chlorosis.  14 

in  chronic  gastritis.  764 

in    chronic    interstitial    nephritis, 
612 

in  chronic  parenchymatous  neph- 
ritis, 594 

in  cirrhosis  of  liver,  903 

in  constipation.  855 

in  erythemia,  61 

in  leukemia.  33  >. 

in  tuberculosis.  416,  417 
in  children.  422 
of  kidne}-,  638 

in   ulcer    of    stomach   and    duod- 
enum. 703 

Karrell.  234 

Lenhartz.  703 

nephritic  test.  605 

Smithies',  716 

A'on  Leube,  703       j--  c-  f^ 
DietFs  crisis,  -§86      5  •-'  "^ 
Diffuse   vesicular    emphysema,    361, 
362 

etiologA'.  362 

patholog}',  363 

S}-mptoms,  364 

treatment,  367 
Disrestive  svstem.  diseases  of,  643 
Digitalis,  278 

contraindications  for  use  of,  282 

coupling.  214.  282 

derivatives.  279 

dosage  of,  281 

indications  for  use  of,  282 

in  dropsy.  281 

physiologic  action  of,  280 
Dilatation  of  heart,  244,  246 
cause,  245 
in  aneur\-sm.  262 

of  stomach,  818.    See  Gastrectasis. 
Diminished  intestinal  sensibility-,  867 

treatment.  869 
Diphtheria   antitoxin   in   asthmatics, 

354 
Diphtheritic  gastritis.  756 
Disease.  Addison's,  80 

Banti's,  47 

Basedow's.  109 

Brieht's,  578.    See  Nephritis. 

Gaucher's,  48.  49 

Glenard's.  862 

Grave's.  109 

Hodgkin's,  44.    See  Hodgkin's. 

Launois's.  151 

Marie's.  151 

Parr>-s.  109 

Schonlein's.  54 

valvular,  of  heart,  242.     See  Val- 
vular Diseases. 

V.'oillez's,  474 


Diseases  of  blood,  3 

of  esophagus,  674 

of  intestines,  837.     See  Intestines. 

of  kidneys,  541.    See  Kidneys. 

of  liver,  874.    See  Liver, 

of  mouth,  643.    See  Mouth, 
as  related  to  svstemic  diseases, 
643 

of  pancreas.  914 

of  parathj-roids,  132 

of  pericardium,  222 

of  peritoneum,  927 

of  pineal  gland,  168 

of  pituitary-  gland,   145 

of  salivar}-  glands,  672 

of  stomach,  684 

of  th^-mus  gland,  133 

of  th3-roid  gland.  92 

of  tongue,  668-672 
Dispensary     treatment     of     tuber- 
culosis, 433.  434,  441 
Displacements  of  kidney,  553.     See 

also  Kidne}-,  Movable. 
Dissemination    of    tuberculosis, 

methods  of,  404 
Distomatosis,  pulmonary.  499 
Diuretics  in  nephritis,  597 
Diverticulum  of  esophagus,  679 

diagnosis,  680 

etiolog}',  679 

prognosis,  680.  681 

symptoms,  680 

treatment,  680 
Drainage   in  peritonitis,   indications 
for.  939 

technic,  939 
Drop   method   of   enteroclvsis,   583, 

940 
Draps}-,  digitalis  in,  281 

in  leukemia,  42 
Dn-  cupping,  technic,  589 

mouth.  672 

pericarditis.  222.  223.  224 
Ductless  glands,  diseases  of,  67 
Duodenal  feeding,  714 

in  carcinoma  of  stomach,  742 
Duodenum,  diseases  of.  684 

ulcer  of.  684.     See  Ulcer. 
Dyspituitaria,  150 
Dyspnea,  toxic,  in  nephritis,  603 

treatment,  616 
Dystrophia   adiposogenitalis,    160 

Echinococcic  c^-st  of  adrenals.  91 
Echinococcus  disease  of  lungs,  497 

etiolog\-.  497 

pathofog}-.  498 

S}-mptoms,  498 

treatment,  499 


INDEX. 


979 


Edema  in  nephritis,  581,  585,  592 
pulmonary,  476 

acute  suffocative,  476 
etiology,  476 
symptoms,  477 
etiology,  476 
pathology,  477 
symptoms,  477 
treatment,  478 
Edestin  test,  733 
Effusion,  pericardial,  222,  225 
pleural,  499,  509,  510._    See  Pleu- 
ritis,       Serofibrinous,      and 
Pleural  Fluids. 
Eggs  and  milk  in  pulmonary  tuber- 
culosis, 417,  418,  419 
Egophony,  513 
Elastic  fibers  in  sputum,  379 
Electric  light  bath,  587 
Electrical  treatment  of  chronic  gas- 
tritis, 773 
Electrocardiograph,  203,  206 
Emetic  cough,  378 
Emetin  hydrochlorid  in  hepatic  ab- 
scess, 908 
in  pyorrhea,  654 
Emphysema,  361 
atrophic,  362 
compensatory,  362,  369 

pathology,  369 
diffuse  vesicular,  361,  362 
etiology,  362 
pathology,  363 
symptoms,  364 
treatment,  367 
hypertrophic,  362 
interlobular,  362 
interstitial,  362 
large-lunged,  362 
local,  362 
senile,  362,  369 
pathology,  369 
symptoms,  370 
treatment,  370 
small-lunged,  362 
types,  361 
Empyema,  521 
complications,  523 
diagnosis,  524,  525 

from  subphrenic  abscess,  962 
etiology,  521 
loculated,  522 

diagnosis,  525 
pathologic  521 
physical  signs,  522 
results  of,  523 
symptoms,  522 
treatment,  524 
operative,  526 
Emulsion,  Koch's  bacillary,  431 


Endameba  buccalis,  651 
Endemic  cretinism,  104 
Endocarditis,  236,  247 
chorea  in,  241 
chronic,  237 
diagnosis,  238 
etiology,  236,  247 
malignant,  237 
pathology,  237,  247 
prognosis,  239 
treatment,  239 

by  eliminating  underlying  cause, 

240 
by  elimination,  240 
by  rest,  239 

during  convalescence,  240 
symptomatic,  240 
vaccine,  241 
Endomyces  albicans,  658 
Endothelioma  of  peritoneum,  966 
Enteralgia,  867 

treatment,  869 
Enteritis,  acute,  837 
symptoms,  837 
treatment,  838 
as  a  cause  of  myocarditis,  229 
chronic,  839 
diet  in,  840 
forms  of,  839 
symptoms,  839 
treatment,  840 
chronic  catarrhal,  839 
diarrhea  and,  841 
in  infants,  841 
etiology,  841,  842 
prophylaxis,  843 
symptoms,  842 
treatment,  843 
pseudomembranous,  839 
ulcerative,  839 
Enteroclysis,    bv    Murphy    method, 
583,  940 
continuous,  583 
in   peritonitis,   940,   944 
Enterocolitis,  841 
Enteroptosis,  862 
diagnosis,  865 
etiology,  863 
Glenard's  test,  865 
symptoms,  864 
treatment,  866 
indications,  866 
Enterospasm,  868 

treatment,  869 
Eosinophilia  in  asthma,  351 
Epidemic  sore  throat,  665 
Epinephrin  in  heart-lilock,  219 

in  heart  diseases,  285 
Epistaxis,  renal.  564 
Epithelial  casts,  573 


980 


INDEX. 


Erythemia,  61 
diet  in,  62 
symptoms,  61 
synonym,  61 
treatment,  62 
X-ray,  62 
Esbach's  albuminometer,  572 
Esbach  test,  571 

Esophageal    bougies,    use    of,    683. 
See  Bougie, 
lavage,  815 
Esophagismus,  678 
etiology,  678 
treatment,  679 
Esophagitis,  812 
acute,  674 
etiology,  674 
symptoms,  675 
treatment,  675 
diagnosis,  816 
treatment,  816 
Esophagus,  carcinoma  of,  677 
symptoms,  677 
treatment,  677 
diseases  of,  674 
diverticulum  of,  679 
diagnosis,  680 
etiology,  679 
prognosis,  680.  681 
symptoms,  680 
treatment,  680 
foreign  bodies  in,  681 
normal  constrictions  of,  684 
stenosis  of,  675 
stricture  of,  681 
diagnosis,  682 
etiology,  681 
normal,  684 
prognosis,  683 
symptoms,  682 
treatment,  683 
ulcer  of,  675 
etiology,  675 
symptoms,   676 
treatment,  676 
Essential  hematuria,   564,   565 
Exercises  in  chronic  heart  diseases, 
292,  298 
in    pulmonarv    tuberculosis,    412, 

414,  415,  416 
Oertel's  climbing,  297 
Exophthalmic  goiter,  109 
asthenic  stage  of,  110 
erethic  stage  of,  109 
etiology,  112,  114 
ligation    of    thyroid    vessels    for, 

117 
myxedematous  stage  of,  110 

symptoms,  112 
pituitary  extract  in,  114 


Exophthalmic  goiter,  rest  in,  114 
results  of  thyroidectomy  in,  117 
sthenic  stage  of,  109 

symptoms,  110 
synonyms,  109 

thymus  involvement  in,   112,  115 
S3nnptoms,   112 
treatment,  118 
tonsillectomy  in,   114 
transitional  stage  of,  109 

symptoms,   112 
treatment,  113 
surgical,  116 
X-ray,  115 
Expectoration   in  pulmonary  tuber- 
culosis, Zll 
disposal  of,  404 
Exploratory   laparotomy   in   gastric 

cancer,  735 
Extract,    pituitarv,     149.      See    Pi- 

tuitar3^ 
Extrasystoles,  208 
etiology,  208 
treatment,  208 
Exudate  vs.  transudate,  differentia- 
tion of  pleural,  500 

Facial  characteristics  of  pulmonary 

tuberculosis,  383 
Failure,  causes  of  cardiac,  245 
of  cardiac  compensation  in  neph- 
ritis, treatment  of,  614 
Fatty  casts,  573 

degeneration    of   liver,   909.      See 

Liver, 
heart,  231 

infiltration    of    liver,    910.      See 
Liver. 
Febrile  diarrhea,  841 
Fecal  stasis,  559 
diagnosis,  559 
Feeble  breathing  in  tuberculosis,  395 
Feeding,  duodenal,  714,  742 
Fetid   stomatitis,  659.     See    Stoma- 
titis, Ulcerative. 
Fever  blisters,  649 
etiology,  649 
treatment,  649 
hay-,  358.     See  Hay-fever, 
in    pulmonarv    tuberculo'sis,    379, 
380,  456 
Fibers,  elastic,  in  sputum,  379 
Fibrillation,  auricular,  212 
etiology,  212 
in  arteriosclerosis,  271 

treatment,  273 
prognosis,  214 
symptoms,  212 
treatment,  214 


INDEX. 


981 


Fibrinous     bronchitis,      337.        See 
Bronchitis. 

pericarditis,  222 

pleuritis,    acute,    502.      Sec    Pleu- 
ritis. 
Fibroid  phthisis,  400,  401 
Fibroma  of  adrenals,  91 

of  peritoneum,  963 

of  tongue,  671 
F'ibrous  goiter,  123 

tissue    formation   in    tuberculosis, 
371,  372 
Fingers,    clubbed,    in    tuberculosis, 

384 
Fissures  of  lios,  648 

treatment,  649 
Fistula-in-ano  in  puhiionary  tuber- 
culosis, 468 
Floating  kidney.  554.    See  also  Kid- 
ney, Movable. 
Flutter,  auricular,  211 

prognosis,  212 

symptoms,  211 

treatment,  212 
Follicular      stomatitis,     656.        See 

Stomatitis  Aphthous. 
Foramen  ovale,  patent,  249. 
Foreign  bodies  in  esophagus,  681 
Formol  index,  733 
Foul  breath,  650 

etiology,  650 

treatment,  650 
Fovirler's  position,  944  * 

Fresh   air  treatment  of  pulmonary 

tuberculosis,  409 
Frohlich's  syndrome,  160 
Function,  tests  for  renal,  604 
Functional  hypoadrenia,  72 

etiology,  73 

prophylaxis,  74 

symptoms,  72 

treatment,  75 

Gall-stone  colic,  893 

impaction,  892,  895 
Gall-stones,  892 

composition,  892 

size,  892 
Ganglioneuroma  of  adrenals,  91 
Gangrene,  pulmonary,  484 

differentiated  from  abscess,  485 

etiology,  484 

pathology,  484 

symptoms,  485 

treatment,  485 
Gangrenous    stomatitis,    661.      See 

Stomatitis. 
Gastrectasis,  818 

acute,  818 

continuous  lavage  in,  822 


Gastrectasis,  diagnosis,  821 
from  megalogastria,  818 
from  pyloric  obstruction,  818 
etiology,  819 
forms  of,  818,  819 
objective  findings  in,  820 
proo^nosis,  821 
symptoms,  820 
treatment,  821 
Gastric  abscess,  757 
crises    of    cerebrospinal    syphilis, 
826 
diagnosis,  829 
prognosis,  830 
spinal  fluid  in,  830 
symptoms,  827 
treatment,  831' 

between  attacks,  835 
lavage,  767,  769 

in  acute  'Peritonitis,  942 
in  gastric  carcinoma,  739 
Gastritis,  749 
acida,  762 

acute  catarrhal,  750 
infectious,  755 
etiology,  755 
pathology,  756 
prognosis,  756 
symptoms,  756 
treatment,  756 
serum,  756 
phlegmonous,  757 
etiology,  757 
mortality,  759 
pathology,  758 
symptoms,  758 
treatment,  759 
simple,  750 
etiology,  750 
prognosis,  750 
treatment,  751 
of  fever,  753 
of  nausea,  753 
of  pain,  753 
of  vomiting,  752 
suppurative,  757 
alcoholic,  779 

treatment,  779 
anacida,  762 

treatment,  778,  779 
atrophic,  761 

diagnosis,  761 
chronic,  759 
'  diet  in,  764 
drugs  in,  776 
etiology,  7i>9 
forms  of,  762 
lavage  in,  767.  769 
mineral  waters  in,  770 
prognosis,  762 


082 


INDEX. 


Gastritis,  treatment,  763 
balneological,  770 
dietetic,  764 
direct,  764 
electrical,  ITi 
mechanical,  767 
medicinal,  776 
prophylactic,  763 
croupous,  756 
diagnosis,  749 
diphtheritic,  756 
hypertrophic  glandular,  760 

diagnosis,  760 
membranous.  756 
subacida,  762 

treatment,  774,  778 
toxic,  753 
etiology,  753 
pathology,  754 
prognosis,  754 
treatment,  754 
types  of,  750 
Gastroenterostomy  for  gastric  can- 
cer, 738 
Gastro-intestinal      disturbances      in 
leukemia,  41 
in    pulmonar\r    tuberculosis,    381, 
441 
Gastroptosis,    862.      See    also    En- 

teroptosis. 
Gauchers  disease,  48,  49 

type  of  splenomegaly,  48,  49 
Geographical  tongue,  669 

treatment,  670 
Germicidal  action  of  thyroid  secre- 
tion, 97 
Gigantism,   151 
symptoms,   152 
treatment,  154 
Gingivitis,  650 
etiolog3^  650 
treatment,  651 
Glands,   diseases  of  salivary,  672 

inflammation   of  parotid,  672 
Glenard's  disease,  862 

test,  865 
Glomerulonephritis,  578,  579,  585 
Glossitis,  acute,  668 
etiology^  668 
prognosis,  668 
symptoms,  668 
treatment,  668 
chronic,  669 
etiology,  669 
s}-mptoms,  669 
treatment,  671 
Gluzinski  test,  692,  m 
Goiter,   118 
colloid,  123 
congenital,  120,  126 


Goiter,  treatment,  126 
constrictive,  123 
cystic,  123 
etiology^  119 

exophthalmic,    109.      See    Exoph- 
thalmic Goiter. 
fibrous,  123 
hemorrhagic,   123 
hyperthyroid,  119,  122 

treatment,   122 
hypothyroid  degenerative,  120,  123 
etiology,  123 
sj^mptoms,  123 
treatment,  124 
varieties,  123 
indications  for  operation  in,  124 
intrathoracic,   123 
linsrual,  123 
malignant,  120,  125 

treatment,  125 
simple  hypothyroid  non-toxic,  119, 
120 
etiology,  120 
treatment,  120 
sjmonyms,  118 
toxic,  119,  122 

treatment,  122 
t\-pes  of,  119 
Gonorrhea  of  mouth,  667 
Grafting,  thyroid,   105 
Granular  breathing  in  tuberculosis, 
395 
casts^  573 
Grave's  disease,  109 
Green  cancer,  43 

sickness,  9 
Grocco's  triangle,  517 
Gummata,  of  liver,  912 
of  lungs,  489,  491 
of  tongue,  670 
G^-mnastic    exercises    in    heart    dis- 
eases, 292 

Haeser,  coefficient  of,  547 
Hanot's  cirrhosis  of  liver,  899 
Hay-asthma,    351,    358.      See.  also 

Hav-fever. 
Hay-fever,  358 
etiology,  358 
prophylaxis,  360 
treatment,  359 
specific,  360 
Heart  action,  normal,  242 
raoid,  247 
slow,  242,  243 
alternation  of.  219 
diagnosis,  220 
etiology,  219 
prognosis,  220 
treatment,  221 


INDEX. 


983 


Heart-block,  216,  243 
etiology,  216 
in  arteriosclerosis,  271 

treatment,  273 
prognosis,  218 
symptoms,  217 
treatment,  218 
dilatation  of,  244,  246 

cause,  245 
disease  in  nephritis,  600  ' 
drugs,  use  of,  278 
exercises   in   chronic   diseases   of, 

292 
failure,  causes  of,  245 
fatty,  231 

hidden   focus  of  infection  in  dis- 
turbances of,  215 
hypertrophy  of,  244,  246,  254 
in  aneurysm,  262 
in  arteriosclerosis,  268 
in  nephritis,  602 
irregularities  of,  202 
massage  in  diseases  of,  296 
muscle,  functions  of,  203 
palpitation  in  tuberculosis,  382 
physiology  of,  203 
pituitary    extract   in    diseases    of, 

285 
premature    contractions    of,    208, 
243 
etiology,  208 
treatment,  208 
rate  of  beat,  242 
rheumatism  of,  237,  240 
senile,  256 
shaggy,  222 
stimulation  of,  through   adrenals, 

71 
valves,  rupture  of,  254 
valvular  disease  of,  242.    See  Val- 
vular Disease. 
Heller's  blood  test,  567,  571 
Hemangioma  of  tongue,  671 
Hematemesis  in  anemia,  28 

in  cirrhosis  of  liver,  905 
Hematoma  of  adrenals,  87 

treatment,  88 
Hematuria,  563 

determining    source    of    bleeding 

in,  564 
diagnosis,  564 

from  hemoglobinuria,  564,  566 
essential,  564 

treatment,  565 
etiologv,  563 
idiopathic,  564 

treatment,  565 
treatment,  565 
Hemic  murmurs,  6,  10 
Hemoglobinuria,  565 


Hemoglobinuria,  diagnosis,  567 
from  hematuria,  564,  566 

etiology,  566 

paroxysmal,  566 
symptoms,  566 

treatment,  568 
Hcmopericardium,  222 
Hemophilia,  56 

coagulation  time  in,  57 

differentiated  from  purpura,  58 

etiology,  56,  57 

hereditary  transmission  of,  57,  58 

renal,  564 

synonym,  57 

treatment,  59 

by  transfusion,  59 
serum,  59 
Hemoptysis,  causes  of,  380,  451 

treatment,  452,  453 
Hemorrhages,  adrenal,  85 

cerebral,  in  nephritis,  616 

in  bronchiectasis,  342 

in  cirrhosis  of  liver,  905 

in  gastric  ulcer,  692 
treatment,  698,  721 

in  leukemia,  43 

in  pernicious  anemia,  28 

pancreatic,  916 

pulmonary,  causes  of,  380,  381 

renal,  causes  of,  563 
Hemorrhagic  diathesis,  56 

peritonitis,  931 

pleuritis,  526 
Hemothorax,  528 

treatment,  529 
Henle,  loop  of,  545 
Henoch's  purpura,  54 
Herpes  labialis,  649 

etiology,  649 

treatment,  649 
Herpetic      stomatitis,      656.        See 

Stomatitis,  Aphthous. 
Herzfehlerzellen,  475 
Hippuric  acid,  551 

amount  of,  551 

identification    of,    551 

origin  of,  551 
His,  bundle  of,  203 
Hoarseness     in     pulmonary     tuber- 
culosis, 380 
Hodgkin's  disease,  44 

arsenic  in,  46 

blood  picture  in,  45 

differential  diagnosis,  45 

prognosis,  45 

salvarsan  in,  46 

symptoms,  44 

synonyms,  44 

tonsillectomy  in,  47 

treatment,  45 


084 


INDEX. 


Hodgkin's  disease,  treatment,  serum, 
47 

surgical,  47 
tuberculin,  46 
vaccine.  46 
X-rav.  46 
Hoffman's  sign,  132 
Home    treatment    of    tuberculosis, 

407,  408 
Horseshoe  kidney.  553 
Hospital    treatment    of    pulmonarj' 

tuberculosis,  406,  407.  408 
Hot  air  bath,  technic,  587 
Hot  pack,  technic,  586 
Hour-glass  contraction  of  stomach. 

692 
Hum,  A-enous,  in  anemia.  6 

in  chlorosis,  10 
Hyaline  casts,  572,  573 
Hydronephrosis,  625 
acquired,  625 
congenital,  625 
diagnosis,  626 
etiology-,  625 
sj-mptoms,  625 
treatment,  626 
Hydropericardium.  222 
Hydrotherapy  in  chlorosis.   13 
in    pulmonary    tuberculosis,    422, 
456 
Hydrothorax,  528 
etiologA',  528 
sjTTiptoms,  528 
treatment,  528 
Hyperadrenia.  84 
etiolog}',  84 
treatment,  86 
Hyperemia    of    kidney,    575.       See 

Kidney. 
Hypernephroma.  88 
of  adrenals.  90 
of  kidney.  89,  639 

diagnosed  from  calculus,  89 
S}-mptoms,  88 
treatment,  89 
HjT)erplasia  of  thj^mus,  140 
etiolog}'.  140 
treatment.  143 
Hyperpituitaria.  149 
and  diabetes  insipidus.  150,  162 
etiolog\',  150 
following  hvpopituitaria,  150,  153, 

159,  160 
treatment,  155 
surgical,  155 
indications  for,  155,  156 
Hypersecretion  of   salivary  ^glands, 
672.     See  Ptv-alism. 
of  stomach  in  ulcer,  692 
treatment,  719 


Hypertension,  276,  277 

in  nephritis,  treatment  of,  615 
treatment,  277 
Hyperth^'roid  goiter,  119,  122 
H}-perthyroidia,    109.      See    Exoph- 
thalmic Goiter. 
Hj-pertrophic  cirrhosis  of  liver,  898. 
See  Liver. 
emphA'sema,  362 
glandular  gastritis,  760 
pulmonary  osteoarthropathy,  342 
pyloric  stenosis,  804 
H\-pertrophy  of  heart,  244,  246,  254 
in  aneurj-sm,  262 
in  arteriosclerosis.  268 
in  nephritis,  602 
HyphomA-cetic  stomatitis,  658.     See 

Thrush. 
H3T)0adrenalism.  12 
Hypoadrenia,  72 

chronic  progressive,  80 
etiolog3%  80 
patholog}-,  80 
symptoms,  80.  81 
treatment,  81 
classes,  72 
functional.  72 
etiolog\^  Ti 
prophylaxis.  74 
SATnptoms.  72 
treatment,  75 
terminal,  11 
etiolog}',  11 
pathology,  11 
sj-mptoms,  78 
treatment,  79 
HA-podermic  administration  of  iron, 

12 
Hypoepinephry,  IZ 
Hypogastric  neuralgia.  867 

treatment,  869 
Hypoparathyroidea,  129 
symptoms.  129 
treatment.  131 
Hypopituitaria.   160 
etiolog}-,    162 
Lorain  t\"pe  of,  161 
secondary  to  hyperpituitaria,  150, 

153,  159.  160 
SATTiptoms,  160 
treatment,  163 
H}'potension,  277 
H],T)othymia,  135 

etiology-,  135 
Hj^othyroid.     degenerative     goiter, 
■  120.  123.  124 
non-toxic  goiter,  119,  120 
Hj-pothyroidia.  98 
and  idiocy.  136 
etiologv,  100 


JNUEX. 


985 


Hypothyroidia,  progressive,  102.  See 
Myxedema. 

symptoms,  99 

treatment,  101 
Hypothyroidism,  98 

Idiocy  and  hypothyroidia,  136 
and  the  thynnis  gland,  135,  136 
Mongolian,  136 
pathology,  137 
symptoms,  136 
treatment,  137 
Idiopathic   hematuria,   564,   565 
Iliac  abscess,  849 
phlegmon,  849 
Immunity  in  tuberculosis,  372 
Impaction  of  gall  stones,  892,  895 
Incomplete  myxedema,  98 
Index,  formol,  73Z 

peptic,  72)Z 
Indican,  test  for,  561 
Infantile  myxedema,  103.     See  Cre- 
tinism, 
splenic  anemia,  50 
arsenic  in,  51 
etiology,  50 
iron  in,  51 
pathology,  51 
symptoms,  50 
synonym,  50 
treatment,  51 
Infantilism,  myxedematous,  106 

treatment,  107 
Infections  of  mouth,  645 

pulmonary,  463,  464,  472 
Infectious  gastritis,  acute,  755.     See 

Gastritis. 
Inflammatory  diarrhea,  841 
Inhalations  in  bronchiectasis,  344 

in  bronchitis,  330 
Ink  polygraph,  203,  205 
Inoculation  test  for  tubercle  bacilli, 

379 
Instruments,    blood-pressure,    274 
Insufficiency,   parathyroid,   129  ■ 
symptoms,  129 
treatment,  131 
pineal,  172 
pituitary,  160 
testicular,  186,  187 
thyroid,  98.     See  Hypothyroidia. 
Interlobular  emphysema,  362 
Interstitial  emphysema,  362 
Intestinal  atony,  867 
treatment,  869 
neuroses,  867 

treatment,  868 
obstruction,  859 
acute,  859 
etiology,  859 


Intestinal    atony,    acute,    symptoms, 
860 
treatment,  861 
chronic,  859 
etiology,  860 
symptoms,  860 
treatment,  862 
complete,  859 
etiology,  859,  _860 
incomplete,  859 
mortality,  861 
treatment  861 
types  of,  859 
parasites,  anemia  due  to,  6 
tuberculosis,  446,  871.    See  Tuber- 
culosis, 
in  infants,  871 
primary,  871 
secondary,  872 
symptoms,  871 
treatment,  872 
Intestines,  carcinoma  of,  869 
etiology,  869 
symptoms,  870 
treatment,  870 
diminished  sensibility  of,  867 

treatment,  869 
diseases  of,  837 
neuralgia  of,  867 
treatment,  869 
secretory  disturbances  of,  867 
strangulation  of,  859 
etiology,  859 
treatment,  861 
syphilis  of,  872 
pathology,  872 
sex  incidence  of,  873 
treatment,  873 
tuberculosis    of,    446,    871.      See 
Tuberculosis. 
Intrathoracic  goiter,   123 
Intratracheal  injections  in  bronchi- 
ectasis, 345 
Intussusception,  859 
etiology,  859 
treatment,  861 
Inunctions,  oil,  451 
Iodides  as  cardiac  drugs,  284 
lodin,  absorption  of,  by  thyroid,  95 

compound,  Kendall's  alpha,  95,  97 
lodothyrin,  92,  94 
lodothyroglobulin,  94 
Ipecac  in  pyorrhea,  654 
Iron,  hypodermic  administration,  12 
in  anemia,  7 
in  chlorosis,   11 
in  infantile  splenic  anemia,  51 
in  leukemia,  39 
in  purpura,  55 
in  tuberculosis,  459 


986 


INDEX. 


Irregularities,  cardiac,  202 
Isthmus,  Kronig's  392,  393 

Jaffe's  test,  551 
Jaundice,  877 

acute  infectious,  881 

avenues  of  infection  in,  887 
etiology,  881 
history  of,  882 
mortality  from,  881,  883 
prevalence  of,  881,  882,  886 
among  rats,  887 
among  troops,  886 
seasonal,  884,  885 
rats  as  carriers  of,  882,  885,  886, 

887 
symptoms,  881,  883 
transmission  of,  884 
treatment,  890 
albuminuria  in,  569 
catarrhal,  877 
diet  in,  879 
etiology,  877,  878 
pathology-,  878 
prognosis,  879 
symptoms.  878 
treatment.  879 
etiology,  877 
trench,  883 
Jejunostomy,  738 
Joffroy's  sign,  10 

Karrell  diet  in  myocarditis,  234 
Kendall's  alpha  iodin  compound,  95, 

97 
Kidney,  abscess  of,  627 
absence  of,  552 
adenoma  of,  639 
amyloid  degeneration  of,  618 

etiology,  618 

pathology,  618 

symptoms,  618 

treatment,  619 
anatomy  of.  542 
anemia  of,  574 

etiology,  574 

treatment,  575 
anomalies  of,  552 
arteriosclerotic,  599 
blood  supply  of,  544 
carcinoma  of,  639 
circulatory  disturbances  of,  574 
congenital  cystic  degeneration  of, 
639 

etiology,  639 

patholo<n',  639 
diseases  of,  541 
displacements  of,  553 

acquired,  553 

congenital,  553 


Kidney,   floating,   554.      See    "Mov- 
able" Kidney,  below, 
histology  of,  543 
horseshoe,  553 
hyperemia  of,  575 

etiology,  575 

passive,  576 

prognosis,  576 

symptoms,  575 

treatment,  576 
hypernephroma  of,  89,  639 
large  white,  591 
malformation  of,  552 
movable,  553,  862 

classification  of,  553 

diagnosis,  556,  557 

etiology,  554,  864 

indications  for  operation  in,  561 

symptoms,  555 

treatment,  541,  557 
nerve  supply  of,  544 
palpable,  553 

palpation  of,  technic,  556 
physiology  of,  545 
ptosis  of,  553 
passive  hyperemia  of,  576 

differentiated     from     nephritis, 
577 

etiology,  576 

pathology,  576 

symptoms,  577 

treatment,  577 
pyogenic  infections  of,  626 

etiology,  627 

indications  for  operation  in,  631 

pathology,  627 

prophylaxis,  629 

symptoms,  628 

treatment,  630 
sarcoma  of,  639 

stones,   619.     See   also  Nephroli- 
thiasis. 

composition,  619 
tuberculosis  of,  633 

diagnosis,  635 

diet  in,  638 

pathology,  633 

source  of  infection  in,  633 

symptoms,  634 

treatment,  636 
tuberculin,  638 
tumors,  639 

sjTnptoms,  639 

treatment,  639 
white,  591 
Klondike  bed,  410 
Koch's  bacillary  emulsion,  431 

old  tuberculin,  431 
Kronig's  isthmus,  392,  393 


INDEX. 


987 


Laboratory  findini^s   in   gastric  car- 
cinoma, 734 
Laennec's    cirrhosis    of    liver,    899. 

See  Liver. 
Laparotomy,  exploratory,  in  gastric 

cancer,  735 
Large-Iungcd  emphysema,  362 
Large  white  kidney,  591 
Laryngitis,   tuberculous,  467 

treatment,  467 
Launois's  disease,  151 
Lavage,  esophageal,  815 
gtistric,  767,  769 

in  acute  peritonitis,  942 
in  gastric  carcinoma,  739 
continuous,  822 
Lenhartz  diet,  703 
Leucocytic  casts,   573 
Leucoplakia,  670 
etiology,  670 
symptoms,  670 
treatment,  671 
Leukemia,  29 
acute,  30 
arsenic  in,  Zl 
atoxyl  in,  38 
bacterial  toxins  in,  40 
benzol  in,  35 
blood  picture  in,  31 
cardiac  disturbances  in,  42 
chronic,  30 

defibrinated  blood  in,  40 
diet  in,  ZZ 
etiology,  29 
gastro-intestinal    disturbances    in, 

.41 
iron  in,  39 
lymphatic,  30 
myelogenous,  30 
salvarsan   in,   Zd 
sodivim  cacodylate  in,  39 
splenectomy  in,  41 
thorium-X  in,  Zl 
treatment,  32 
of  dropsy,  42 
of  hemorrhages,  43 
of  special  symptoms,  41 
tuberculin,  40 
X-ray,  33 

contraindications  to,  34 
types  of,  30 
varieties  of,  30 
Ligation   of  thyroid   vessels   in   ex- 
ophthalmic goiter,  117 
Lightning  pains  in  anemia,  29 
Lingual  goiter,  123 
Lipoma  of  adrenals,  91 

of  peritoneum,  963 
Lips,  fissures  of,  648 
treatment,  649 


Liver,  abscess  of,  90S 
emctin  in,  908 
etiology,  906 
sequelje,  907 
symptoms,  906 
treatment,  907 
acute  yellow  atrophy  of,  908 
etiology,  909 
pathology,  908 
symptoms,  909 
treatment,  909 
adenoma  of,  913 
amyloid   disease  of,  911 
etiology,  911 
symptoms,  911 
treatment,  911 
anatomical  relations  of,  874 
angioma  of,  913 
carcinoma  of,  913 
cirrhosis  of,  898 
atrophic,  898 

pathology,  899 
biliary,  898,  899 
etiology,  899,  900 
pathology,  899 
symptoms,  902 
diet  in,  903 

etiology,  875,  898,  900    • 
Hanot's,  899  _ 
hemorrhages  in,  905 
hypertrophic,  898 
etiology,  900 
pathology,  899 
symptoms,  901 
Laennec's,  899 
portal,  898 
atrophic,  899 
forms  of,  899 
h3rpertrophic,  899 
symptoms,  901 

of  terminal  stage,  905 
treatment,  902 

of  hemorrhages,  905 
surgical,  904 
types  of,  898 
cysts  of,  914 
diseases  of,  874 
fatty  degeneration  of,  909 
etiology,  909 
pathology,  909 
symptoms,  910 
treatment,  910 
fatty  infiltration  of,  910 
patholog}^  910 
symptoms,  910 
treatment,  911 
physiology  of,  874 
sarcoma  of,  913 
sclerosis  of,  898 
syphilis  of,  912 


988 


INDEX. 


Liver,  syphilis  of,  acquired,  912 
congenital,  912 
pathology,  912 
symptoms,  912 
treatment,  913 
tuberculosis  of,  913 
tumors  of,  913 
symptoms,  913 
Local  emphysema,  362 
peritonitis,  chronic,  945,  946.     See 
Peritonitis,  Chronic. 
Loculated  empyema,  522 

diagnosis,     525.      See    also    Em- 
pyema. 
Loop  of  Henle,  545 
Lorain  type  of  hypopituitaria,  161 
Loss  of  weight  in  tuberculosis,  381 
Ludwig's  angina,  674  -. 
Lungs,    bacterin    treatment   of    dis- 
eases of,  534 
carcinoma  of,  496 
echinococcus  disease  of,  497 
gummata  of,  489,  491 
sarcoma  of,  496 
tumors  of,  495 
Lymphadenoma,  44 
Lymphatic  leukemia,  30 
Lymphemia,  31 
Lymphocarcinoma     and     Hodgkin's 

disease,  45 
Lymphosarcoma  and  Hodgkin's  dis- 
ease, 45 

Mackenzie's  ink  polygraph,  203,  205 
Macroglossia,  672 
Malformations  of  kidney,  552 
Malignant  endocarditis,  237 

goiter,  120,  125 
Malpighian  pyramid,  543 
Marie's  disease,  151 
Massage  in  chlorosis,  13 

in  heart  diseases,  296 
McBurney's  point,  850 
Mechanical  purpura,  52 

treatment  of  chronic  gastritis,  767 
Megalogastria,  818 
Membrane,  Cargile,  950,  951 
Membranous  gastritis,  756 
Menstrual    disorders,    influence    of 

ovaries  on,  179 
Menstruation,  vicarious,  in  phthisis, 

381 
Mercurial  stomatitis,  662 

symptoms,  662 

treatment,  662 
Metallic  tinkle,  532 
Metastasis     in     gastric     carcinoma, 
728 

in  gastric  sarcoma,  746,  748 
Miliary  tuberculosis,  400 


Milk  and  eggs  in  tuberculosis,  417, 

418,  419 
Mineral  waters  in  chronic  gastritis, 

770 
Mitral  regurgitation,  250 
frequency  of,  250 
physical  signs  of,  250 
prognosis,  248,  250 
with  stenosis,  250 
stenosis,  251 

embolism  in,  249 
etiology,  247 
physical  signs  of,  252 
prognosis,  248 
stages  of,  252 

with  mitral  regurgitation,  250 
with  tricuspid  stenosis,  255 
Moist  rales  in  tuberculosis,  397 
Mongolian  idiocy,   136 
pathology,  137 
symptoms,  136 
treatment,  137 
Morbus  maculosis,  54 
Morphin  in  heart  affections,  284 
Mouth,  diseases  of,  643 

as  related  to  systemic  diseases, 

643 
treatment  of,  647 
dry,  672 
gonorrhea  of,  (::^1 

treatment,  667 
infections  of,  645 
sepsis  of,  646 
as  a  cause  of  cancer,  726 
treatment,  695 
syphilitic  affections  of,  666 
treatment,  666 
Movable  kidney,  553.     See  Kidney. 
Mucous  colitis,  845.     See  Colitis. 
Murexid  test,  551  _ 
Murmurs,  hemic,  in  anemia,  6 

in  chlorosis,  10 
Murphy  method  of  enteroclysis,  583, 

940 
Mycotic    stomatitis,    658.      See 

Thrush. 
Myelemia,  31 

Myelogenous  leukemia,  30 
Myocarditis,  228  _ 

and  valvular  disease,  243 
cane  sugar  in,  234 
chronic,  230 

symptoms,  230 
diagnosis,  229,  230 
drugs  in,  235 
elimination  in,  232 
etiology,  228 
Karrell  diet  in,  234 
prognosis,  230 
rest  in,  232 


INDEX. 


989 


Myocarditis,  sequels  to,  231 

syniptoins,  229 

treatment,  231 

indications  for,  231 
of  symptoms,  235 
Myxedema,   102 

etiology,   102,  103 

incomplete,  98 

infantile,  103.     Sec  Cretinism; 

symptoms,   102 

treatment,  103 
Myxedematous  infantilism,   106 

treatment,  107 

Nauheim  baths,  286 

administration  technic,  287 
Nausea  in  acute  gastritis,  treatment 

of,  753 
Neoplasms,     peritoneal,     963.       See 
Peritoneal, 
pulmonary,  495.    See  Pulmonary. 
See  also  Tumors. 
Neosalvarsan  in  aneurysm,  264 

in  pernicious  anemia,  21,  22 
Nephritic  test  diet,  605 
Nephritis,  578 
acute  parenchymatous,  578 
complications,  582 
diet  in,  584 
edema  in,  581,  585 
electric  light  bath   in,  587 
etiology,  578 
dry  cupping  in,  589 
glomerular  tyne,  578,  579,  585 
hot  air  bath  in,  587 
hot  pack  in,  586 
pathology,  579 
pericarditis  in,  582 
pilocarpin  in,  588 
dangers  of,  588 
prognosis,  582 
prophylaxis,  582 
purpura  in,  582 
symptoms,  580 
treatment,  583 

of  edema,  585 
tubular  type,  578,  579,  580 
uremia  in,  582 
urine  in,  581 
venesection  in,  588 
and  arteriosclerosis,  268,  600 
chronic  interstitial,  599 

association   with   heart   disease, 

600 
cardiac  hypertrophy  in,  602 
diet  in,  612 
dyspnea,   toxic,   in,  603 

treatment,  616 
etiology,  599 
pathology,  600 


Nephritis,  chronic  interstitial,  relation 
to  arteriosclerosis,  268,  600 
retinal  changes  in,  603 
symptoms,  601 

tests  for  renal  function  in,  604 
creatinin  in  blood,  610 
nephritic  test  diet,  605 
phenolsulphonephthalein,  604 
urea  in  blood,  608 
uric  acid  in  blood,  606 
treatment,  611 
climatic,  612 

of  cerebral  hemorrhage,  616 
of  dyspnea,  616 
of  failure  of  cardiac  compen- 
sation, 614 
of  hypertension,  615 
of  uremia,  617 
uremia  in,  604 
symptoms,  604 
treatment,  617 
urine  in,  602 
chronic  parenchymatous,   589 
anemia  in,  592 
diet  in,  594 
diuretics  in,  597 
edema  in,  592 
etiology,   590 

paracentesis  abdominis  in,  598 
pathology,  591 
prognosis,  592 
symptoms,  591 
thoracentesis  in,  597 
treatment,  593 

tuberculosis  as  a  cause  of,  590 
urine  in,  591 
clinical  classification  of,  541,  578 
complicating  pulmonary   tubercu- 
losis, 464,  465 
differentiated  from  passive  hyper- 
emia of  kidney,  577 
pathological  types  of,  578 
suppurative,  626 
Nephrolithiasis,  619 
etiology,  620 
symptoms,  621 
treatment,  624 
of  renal  colic,  622 
Nephroptosis,  553,  862.    See  Kidney, 

Movable. 
Nen'ous  diarrhea,  868 
treatment,  869 
svmptoms  in  pulmonary  tubercu- 
losis, 383,  449 
Neuralgia,  hypogastric,  867 
treatment,  869 
of  intestines,  867 
treatment,  869 
Neuroses  of  intestines,  867 
treatment,  868 


990 


IKDEX. 


Neurotic  purpura,  52 
Nitrites,  action   of,  283 

dosage,  283 

indications  for  use  of,  283 

in  pulmonary-  tuberculosis,  453 
Nitroglycerin,  283 
Node,  auriculoventricular,  203 

sinoauricular,  203 
Noma,  661.     See  Stomatitis,  Gang- 
renous. 
Non-exudative    peritonitis,    chronic 

general.  952 
Normal  blood-pressure,  270,  276 

Obstruction,     intestinal,     859.       See 
Intestinal  Obstruction, 
pyloric,    801.      See    Pyloric    Ob- 
struction. 
Oertel's  climbing  exercises,  297 
Oil  inunctions,  451 
Old  tuberculin,  Koch's.  431 
Oophorectomy,  effects  of,  174, 178, 179 

in  osteomalacia,  175 
Open-air  schools,  440 
Opium    in    pulmonary    tuberculosis. 

449,  453 
Oral  sepsis,  646 
as  a  cause  of  cancer.  126 
treatment,  695 
Osteoarthropath}-,  hypertrophic  pul- 

monar\%  342 
Osteomalacia,  oophorectomv  in.  175 
O.  T.,  431 

Ovarian  insufficiency,  177 
s^-mptoms,  177 
treatment,  180 
overactivity,  182 
symptoms.  182 
treatment.  183 
Ovaries,  active  principles   of.   175 
and  menstrual  disorders.  179 
disorders  of,  173 

effect  of  removal  of.  174,  178,  179 
functions  of,  173,  174,  175 
transplantation  of,  181 
OveractiA-it\-,     pituitan,-,     149.       See 
Hvperpituitaria, 
testicular   190,   191 
thyroid.  109.     See  Hj'perthvroidia 
and  Exophthalmic  Goiter. 

Pacemaker.  203 

Pack,  technic  of  hot,  586 

Pain  in  gastric  cancer,  729 

treatment  of,  744 
Pains,  thoracic,  in  tuberculosis,  383 
Palpable  kidne}'-,  553 
Palpation  of  kidney,  technic,  556 
Pancarditis,  238 
Pancreas,  carcinoma  of,  921 


Pancreas, carcinoma  of, symptoms,92l 
treatment.  922 
diseases  of,  914 
physiolog],'  of.  914 
rupture  of,  936 
Pancreatic  calculi,  919 
etiology-.  919 
s\Tnptoms,  919 
treatment.  919 
cysts,  920 
etiolog}',  920 
S}Tnptoms,  920 
treatment,  921 
hemorrhage,  916 
etiolog],'.  916 
symptoms,  916 
treatment,  916 
Pancreatitis,  acute,  916 
etiolog3\  916 
symptoms,  917 
treatment,  917 
chronic.  918 
etiolog^^  918 
S3rmptoms,  918 
treatment,  919 
Paracentesis     abdominalis,     technic, 
598,  969 
of  pericardium,  227 
thoracis.  514,  597 
dangers.  521 
indications.  516 
technic,  517,  597 
Paraganglioma  of  adrenals.  91 
Paralysis    agitans.    parathyroids    in, 

132.  133 
Parasites,     anemia     due     to     intes- 
tinal, 6 
Parasitic  form  of  thj^roiditis,  108 

stomatitis,  658.     See  Thrush. 
Parathyroids.  93.  126 
anatomy  of,  126 
and  paralysis  agitans.  132.  133 
effect  of  removal  of,  94,  127 
functional  disorders  of,  132 
histology^  of,  127 
insufficiency  of,  129 
symptoms,  129 
treatment,  131 
organic  disorders  of,  132 
phvsiologA'  of,   127 
Paratv-phhti's,  849 
Parietal  peritoneum,  928 
Parotid  glands,  inflammation  of,  672 
etiolog}-,  673 
treatment  673 
Parotitis,  672 

Paroxysmal  hemoglobinuria,  566 
tachycardia,  209 
diagnosis,  209 
prognosis,  209 


INDEX. 


991 


Paroxysmal  tachycardia,  treatment, 

210 
Parry's  disease,  109 
Passive  hyperemia  of  kidnej',  576 
Patent  foramen  ovale,  249 
Pectoriloquy,  398 
Peliosis  rheumatica,  54 
Pelvic   peritonitis,    953.      See    Peri- 
tonitis. 
Peptic  index,  733 
Percussion  of  chest,  technic,  391 
Periapical  abscesses,  653 
Pericardial  adhesions,  222,  225 

effusion,  222,  225 
Pericarditis,  222,  223 

dry,  222,  223,  224 
etiology,  223 
symptoms,  224 

etiology,  223 

fibrinous,  222 

in  nephritis,  582 

plastic,  222 

treatment,  226 

with  eft'usion,  222,  225 
symptoms.  225 
treatment,  227 
Pericardium,  adherent,  222,  225 

aft'ections  of,  222 

hemo-,  222 

hydro-,  222 

paracentesis  of.  227 

physiology  of,  222 
Perigastric  abscess,  692 
Perinephritic  abscess,  632 

etiolog}-,  632 

sjTnptoms,  632 

treatment,  632 
Peritoneal  neoplasms,  963 

benign,  963 
symptoms,  965 
treatment,  966 

malignant,  966 
treatment,  966 
Peritoneum,    absorptive    power    of, 
928 

anatomy,  927 

carcinoma  of,  966 

cysts  of,  963 

danger  zones  of,  929 

diseases  of,  927 

endothelioma  of,  966 

fibromata  of,  963 

functions  of,  930 

lipomata  of,  963 

lymphatics  of,  930 

nerve  supply  of,  929 

parietal,  928 

sarcoma  of,  966 

secretory  function  of,  929 

tumors  of,  9Ci3 


I   Peritoneum,  visceral,  928 
Peritonitis,  acute  general,  927 
bacteria  found  in,  931 
cause  of  death  in,  935 
due  to  colon  bacilli,  933 

to  pneumococci,  931 

to  staphylococci,  933 

to  streptococci,  932 
hemorrhagic  t3-pe,  931 
indications  for  drainage  in,  939 

technic,  939 
indications  for  operation  in,  937 
leucocytosis  in,  934 
patholog}^  930 
.    purulent  type,  931 
serofibrinous  type,  931 
serous  tj-pe,  931 
sources  of  infection  in,  935 
S3Tnptoms,  932,  933 
treatment,  937 

enteroclysis,  940,  944 

feeding,  943 

gastric  lavage,  942 

position  of  patient,  944 

stimulation,  943 

surgical,  938 

use  of  cathartics,  945 
tvpes,  931 
appendicular,  959 
pathology^  959 
symptoms,  959 
treatment,  960 
chronic,  945 
etiolog}-,  945 
general,  946 

non-exudative.  952 

symptoms,  948 

treatment,  951 
local.  945,  946 

etiologv",  946 

pathologv',  946 

prophylaxis.  949.  950 

sjTTiptoms.  946,  947 

treatment,  949.  950 
non-exudative  general,  952 

treatment.  952 
patholog\',  945 
treatment.  949 
non-exudative     chronic     general, 
952 
treatment.  952 
pelvic.  953 

dift'erential  diagnosis,  956 
etiology,  953 
patholog}-,  953 
symptoms,  955 
treatment.  957 
subacute  general.  935 

symptoms,  935 
tuberculous.  946 


992 


INDEX. 


Peritonitis,    tuberculous,    treatment, 

951 
Perit\-phlitis,  849 
Pernicious  anemia,  17 
arsenic  in,  21,  22,  23 
blood  transfusion  in,  -23 
defibrinated  blood  in,  24 
diet  in.  21 
hemorrhages  in,  28 
neosalvarsan  in.  21,  22 
patholog3\  17 
rest  in.  21 
salvarsan  in,  21.  22 

contraindications,  22 
sensorj-  disturbances  in,  29 
serums  in.  25 
splenectomy  in,  26 
contraindications.  26 
mortalit}^  from,  26 
results  of.  26 
SA-mptoms,  20 
treatment,  20 

of  special  s\Tnptoms,  27 
X-ray,  27 
venesection  in,  24 
Phenolsulphonephthalein  test.  604 
Phlebograms.  205 
Phlegmon,  iliac,  849 
Phlegmonous    gastritis,    757.      See 

Gastritis. 
Phosphates  in  urine,  552 
amount  of.  552 
origin  of,  552 
tests  for,  552 
Phosphatic  calculi,  620 
Phthisical  chest.  384 
Phthisis,    371.      See    Tuberculosis, 
Pulmonary, 
fibroid.  400.  401 
florida.  400 
syphilitic,  492 
Pilocarpin  in  nephritis.  588 

dangers  of  use.  588 
Pineal  gland,  anatomj-  of,  168 
diseases  of,  168 
function  of,  169 
histology  of,  168 
insufficiency,  172 
sand,  168 
tumors.  171 
sv-mptoms.  171 
treatment,  172 
Pioe-stem  arter\%  271 
PituitarT,"  bod\-,  anatomy  of.  145 
connection  of.  with  adrenals.  71 
diseases  of,  145 
effect  of  removal  of.   146 
histology-  of.  145 
physiology'  of.  146 
extract,  effect  of,  149 


Pituitar>'    extract    in    exophthalmic 
goiter,  114 
in  heart  diseases,  285 
insufiicienc}',     160.       See     H^-po- 

pituitaria. 
overactiA"its".    149.      See    Hj^perpi- 
tuitaria. 
of  anterior  lobe,  150 
of  posterior  lobe,  150 
tumors,  151 
sjTnptoms,  151 
treatment,  155 
Pitj-riasis   versicolor   in   pulmonar\r 

tuberculosis.  384 
Plastic  pericarditis,  222 
Pleura,   bacterin   treatment  of   dis- 
eases of.  534 
carcinoma  of,  526 
sarcoma  of,  526 
Pleural  effusion,  499,  509,  510.     See 
Pleural  Fluids, 
in  pulmonary-  tuberculosis,  460 
exudate.  500 
fluids,  499,  510 

bacteriology'  of,  502 
cytology-  of,  501 
transudate.  500 
tumors,  526 
diagnosis,  527 
symptoms,  526 
treatment,  527 
Pleuris3\     See  Pleuritis. 
Pleuritis,  acute  fibrinous,  502 
etiology,  502 
pathology,  503 
physical  signs.  504 
S3*mptoms,  504 
strapping  of  chest  in,  505 
treatment,  505 
operatiA'e,  505 
hemorrhagic,  526 

etiology,  526 
in    pulmonan^    tuberculosis,    502, 

503,  507 
purulent,  521.     See  Empyema. 
serofibrinous.  509 

aspiration  of  fluid,  516 
diagnosis,  511 
etiology,  509 

exploratory  puncture  in,  514 
pathology-.  510 
ph3-sical  signs,  511 
SA-mptoms.  511 
thoracentesis,  516 
dangers  of,  521 
indications,  516 
technic,  517,  520 
treatment,  515 
Pneumococci  as  cause  of  peritonitis, 
931 


INDEX. 


993 


Pneumoconiosis,  486 

etiology,  486 

pathology,  486 

prophylaxis,  488 

symptoms,  487 

treatment,  488 
Pneumonia,   tuberculous,  400 

white,  489 
Pneumopericardium,  222 
Pneumothorax,  529 

etiology,  530 

in  bronchiectasis,  348 

in    pulmonary    tuberculosis,    462, 
533 

pathology,  529,  530 

physical  signs,  531 

symptoms,  531 

treatment,  532 
Point,  McBurney's,  850 
Polycythemia,  61 
Polygraph,  ink,  203,  205 
Porches,  sleeping,  409 
Portal   cirrhosis   of   liver,  898,  899. 

See  Liver. 
Position,  Fov^rler's,  944 
Postoperative  tetany,   129 

symptoms,  129 

treatment,  131 
Postural    treatment    of    bronchiec- 

•    tasis,  346 
Pregnancy,     complicating     tubercu- 
losis, 471 

tubal,    differentiated    from    pelvic 
peritonitis,  956 
Premature    contractions    of    heart, 
208,  243 

auricular,  208 

etiology,  208 

in  arteriosclerosis,  270 

treatment,  208 
Prevention   of  tuberculosis,  402 

by  public  education,  405 
Progressive    hypoadrenia,    12.      See 
Hypoadrenia. 

hypothyroidia,     102.      See    Myx- 
edema. 
Protein   sensitization   tests   in 

asthma,  352,  353 
Proteinuria,  Bence-Jones,  570 
Pseudoangina,  255 
Pseudoleukemia,  44 
Pseudomembranous  enteritis,  839 
Ptosis  of  kidney,  553 
Ptyalism,  672 

etiology,  672 

treatment,  672 
Pulmonary   abscess,   478.     See   Ab- 
scess. 

actinomycosis,   493.     See   Actino- 
mycosis. 


Pulmonary  aspergillosis,  499 
blastomycosis,  499 
carcinoma,  496 

congestion,  474.     See  Congestion, 
distomatosis,  499 
edema,  476.     See  Edema. 

acute  suffocative,  476 
gangrene,  484.     See  Gangrene, 
hemorrhages,  causes  of,  381 
infections,    chronic    non-tubercu- 
lous, 472      • 
etiologv,  473 
in  children,  473 
pathology,  473 
physical   signs,  473 
symptoms,  472 
treatment,  473 
neoplasms,  495 
benign,  495 
diagnosis,  496 
malignant,  495 
symptoms,  496 
treatment,  497 
sarcoma,  496 
stenosis,  248,  250,  255 
streptothricosis,  494 
syphilis,  489   ■ 
tuberculosis,  371 
tumofs,  495 
Pulse,  rapid,  242 
rate  in  tuberculosis,  382 
slow,  242,  243 
Pulsus  alternans,  219 
Purpura,  52 
arthritic,  52 
cachectic,  52 

differentiated  from  hemophilia,  58 
etiology,  52 
hemorrhagica,  54 
Henoch's,  54 
in  nephritis,  578 
mechanical,  52 
neurotic,  52 
peliosis  rheumatica,  54 
rheumatica,  52 
simplex,  53 

etiology,  53 
treatment,  54 
Purulent  peritonitis,  931 

pleuritis,  521.     See  Empyema. 
Putrid  sore  throat,  659.     See  Stom- 
atitis, Ulcerative. 
Pyelitis,  626  _ 
Pyelonephritis,  626 
suppurative,  626 
Pyloric  obstruction,  801 

differentiated     from    gastrectasis, 
818 
from  ulcer,  692 
etiology,  801 


63 


994 


INDEX. 


Pyloric  obstruction,  prognosis,  802 

symptoms,  801 

treatment,  802 
Pyloric  stenosis,  congenital,  804 

classification.  804 

diagnosis,  807 
differential.  808 

etiology-.  804 

mortality,  808 

objective  findings,  807 

patliology,  805 
•    prognosis,  808 

symptoms,  806,  807 

treatment.  808 
Pylorospasm,  796 

etiolog}',  796 

prognosis,  798 

symptoms,  797 

treatment,  799 

t>T3es,  797 
Pyogenic  infections  of  kidney,  626. 

See  Kidney. 
Pyonephrosis,  627 
P}^opneumothorax,  533 

differentiated  from  subphrenic  ab- 
scess, 962 
Pyorrhea  alveolaris,  651 

diagnosis,  653 

emetin  hydrochlorid  in,  654 

etiology.  651 

ipecac  in,  654 

symptoms,  653 

treatment,  654 

Radium  treatment  of  gastric  cancer, 

745 
Rales     in     pulmonary    tuberculosis, 

396,  397 
Rapid  heart  action,  242 
Rats     as     carriers     of     spirochseta 
icteroh^emorrhagicje.      882, 
885.  886,  887 
Reaction,  Wolff' -Junghan,  733 
Rectal  feeding  in  gastric  cancer,  742 
Regurgitation,  aortic,  253 
etiology,  253 
physical   signs  in.  253 
prognosis,  248 
sudden  death  in,  248 
mitral,  250 

frequency  of,  250 
physical   signs,  250 
prognosis,  250 
with  stenosis,  250 
tricuspid,  254 
etiology,  254 
prognosis,  248 
symptoms,  254 
Renal  calculus  diagnosed  from  hy- 
pernephroma, 89 


Renal  colic,  621 
etiology,  621 
treatment,  622 
epistaxis,  564 
function  tests,  604 
hemophilia,  564 
hemorrhages,  causes  of,  563 
Resection  of  stomach,  736 
Resistance    exercises    in    heart   dis- 
ease, 292,  298 
Resonance,     vocal,     in     pulmonarj^ 

tuberculosis,  398 
Rest  in  myocarditis,  ^232 

in  pulmonary  tuberculosis,  412 
Rests,  adrenal,  68,  88 
Retention    of    urine,    differentiated 

from  suppression,  562 
Retinal  changes  in  nephritis,  603 
Rhagades  of  commissures,  648 
Rheumatic  purpura,  52 
Rheumatism  of  heart,  237,  240 
Rupture  of  heart  valves,  254 
of  pancreas,  936 

Salivary  calculi,  673 

glands,  diseases  of,  672 

hypersecretion     of,     672.       See 
Ptyalism. 
Salts,  urinarj^  552 
Salvarsan  as  a  cardiac  drug,  283 

in  aneurysm,  263 

in  Hodgkin's  disease,  47 

in  leukemia,  36 

in  pernicious  anemia,  21,  22 
Sanatorium    treatment   of   tubercu- 
losis. 406 

advantages,  407 

disadvantages.  407 
Sand,  pineal,  168 
Sarcoma,  and  Hodgkin's  disease,  45 

of  kidnev.  639 

of  liver,  "913 

of  lungs,  496 

of  peritoneum,  966 

of  pleura,  526 

of  stomach,  746.     See  Stomach. 

of  tongue,  671 
Schiff''s  test,  550 
Schonlein's  disease,  54 
Schools,  open-air.  440 
Sclerosis  of  liver.  898 

of  tubercles,  371,  372 
Secretory  disturbances  of  intestines, 
867 

function  of  peritoneum,  929 
Semicretins,   104 
Senile  emphysema,  362,  369 
pathology,  369 
symptoms,  370 
treatment,  370 


INDEX. 


995 


Senile  heart,  256 

Sensibility,      diminished      intestinal, 
867 
treatment,  869 
Sensitization  tests,  protein,  352,  353 
Sepsis,  oral,  646 

as  a  cause  of  cancer,  726 
treatment,  659 
Sergent's  white  line,  80 
Serofibrinous  peritonitis,  931 

pleuritis,  509.     See   Pleuritis. 
Serous  peritonitis,  931 
Serums,  in  gastric  cancer,  746 
in  hemophilia,  59 
in  Hodgkin's  disease,  47 
in  pernicious  anemia,  25 
Shaggy  heart,  222 
Sibilant  rales  in  tuberculosis,  397 
Sickness,  green,  9 
Siderosis,  486 
Sign,  Bacelli's,  514 
Chvostek's,  132 
Hoffman's,  132 
Joffroy's,  10 
Silicosis,  486 
Silver  nitrate  in  ulcer  of  stomach, 

700 
Sinoauricular  node,  203 
Sinus  arhythmias,  207 
Sippy's   treatment   of   gastric   ulcer, 

701 
Skodaic  resonance,  393 
Sleeping  porches,  409 
Slow  heart  action,  242,  243 
Small-lunged  emphysema,  362 
Smithies'  diet,  716 
Smoking  in  pulmonary  tuberculosis, 

447 
Sodium  bicarbonate  in  gastric  ulcer, 
701 
cacodylate  in  anemia,  7 

in  leukemia,  39 
chloride  in  urine,  552 
amount  of,  552 
origin  of,  552 
Solids,  urinary,  547 
Sonorous  rales  in  tuberculosis,  397 
Sore  throat,  epidemic,  665 
putrid,      659.        See      Stomatitis, 
Ulcerative. 
Sores,  cold,  649 
Sources  of  infection  in  tuberculosis, 

402 
Specific     treatment     of     pulmonary 

tuberculosis,  428 
Spermine,  185,  186 
Sphygmograms,  205 
Spirals,  Curshmann's,  351 
Spirochseta  icterohasmorrhagicse,  881 
detection  of,  888,  889,  890 


Spirochreta  icterohjcniorrhagicae,  rats 
as  carriers  of,  882,  885,  886,  887 
recovery  of,  from  urine,  889 
Splanchnoptosis,  862.     See  also  En- 

tcroptosis. 
Splash,  succussion,  532 
Splenectomy  in  leukemia,  41 
in  pernicious  anemia,  26 
contraindications,  26 
mortality,  26 
results,  26 
Splenic  anemia,  47 
infantile,  50 
arsenic  in,  51 
etiology,  SO 
iron  in,  51 
pathology,  51 
symptoms,  50 
S3monyms,  50 
treatment,  51 
pathology,  48 
symptoms,  49 
treatment,  49 

X-ray,  50 
varieties  of,  48 
von  Jaksch's,  48 
Splenomegaly,  47,  48 
Sponging  in  pulmonary  tuberculosis, 

422,  423,  457 
Sporadic  cretinism,  104 
Sputum,  albumin  reaction  of,  379 
-cups,  405 

elastic  fibers  in,  379 
in  tuberculosis,  378 
tubercle  bacilli  in,  378 
Staining  tubercle  bacilli,  378 
Staphylococci     as     cause     of     peri- 
tonitis, 933 
Stasis,  diagnosis  of  fecal,  559 
Status  lymphaticus,  140 
diagnosis,  140 
symptoms,  140 
treatment,.  143 
thymicolymphaticus,   140 
symptoms,  142 
Stenosis,  aortic,  254 
congenital  pyloric,   804.     See   Py- 
loric Stenosis, 
mitral,  251 

embolism  in,  249 
etiology,  247 
physical  signs,  252 
prognosis,  248 
stages  of,  252 

with  mitral  regurgitation.  250 
with  tricuspid  stenosis,  255 
of  esophagus,  675 
pulmonary,  248,  250,  255 
tricuspid,  255 
prognosis,  248 


996 


IXDEX. 


Stenosis,  tricuspid,  with  mitral  ste- 
nosis, 255 
Stereoscopic     examination     in    pul- 
monary tuberculosis,  398 
Stokes-Adams  syndrome,  217 
Stomach,    acute    dilatation   of,    818. 
See  Gastrectasis. 
carcinoma  of,  724 
age  incidence  of,  725 
diagnosis,  728 

laboratory,  731,  72)?>,  734 
■      diet  in,  740 

duodenal   feeding  in,  742 

etiolog}^  725 

exploratory  laparotomy  in,  735 

frequency  of,  724 

gastric  analysis  in,  731 

lavage  in,  739 
gastroenterostomy  for,  737 
gastrostomy  for,  738 
histology  of,  727 
jejunostomy  for,  738 
laboratorjr  findings  in,  734 
metastasis  in,  728 
pain  in,  729 
prognosis,  727 

conditions     influencing,     727, 
734 
rectal   feeding  in,  742 
resection  of  stomach  for,  736 
site  of  growth,  728 
symptoms,  729 

of  inoperabilit^^  730 
of  obstruction,  730 
treatment,  735 
hygienic,  739 
medical,  738,  742 
of  anemia,  743 
of  constipation,  745 
of  pain,  744 
radium,  745 
serum,  746 
surgical,  735 
X-rav.  745 
t3^pes  of,  728 

of  operation  for,  735 
vomiting  in,  729,  730 
catarrh  of,  759 
diseases  of,  684 
resection  of,  736 
sarcoma  of,  746 
duration  of,  746 
etiolog}',  747 
frequency  of,  746 
histology  of,  747 
incidence  of,  747 
location  of,  747 
metastasis  in,  746,  748 
pathology,  747 
physical  signs,  748 


Stomach,  sarcoma  of,  symptoms,  748 

treatment,  749 
syphilis  of,  780 

diagnosis,  784 
X-ray,  783 

forms  of,  781 

frequency  of,  780 

gastric  analysis  in,  783 

histology,  782 

prognosis,  785 

symptoms,  782,  783 

treatment,  785 
tuberculosis  of,  789 

avenues  of  infection  in,  790 

diagnosis,  791 

diet  in,  793 

forms  of,  789^ 

frequency  of,  789 

pathology',  791 

prognosis,  792 

symptoms,  791 

treatment,  792 
tuberculin,  795 
ulcer  of,  684.     See  Ulcer. 
Stomatitis,  aphthous,  656 

etiology^  656 

symptoms,  656 

treatment,  657 
catarrhal,  655 

etiology,  655 

treatment,  656 
fetid,  659.     See  Stomatitis,  Ulcer- 
ative. 
follicular.    656.      See    Stomatitis, 

Aphthous, 
gangrenous,  661 

etiolog},',  661 

symptoms,  661 

treatment,  662 
herpetic.      See    Stomatitis,    Aph- 
thous. 
h3-phom3'cetica,  658.     See  Thrush, 
mercurial,  662 

symptoms,  662 

treatment,  662 
mycotic,  658.     See  Thrush, 
parasitic,  658.     See  Thrush, 
ulcerative,  659 

etiology,  659 

symptoms,  659 

■treatment,  660 
vesicular.      See    Stomatitis,    Aph- 
thous. 
Stones,  calcium  oxalate,  619 
kidney,  619.     See  Nephrolithiasis, 
phosphatic,  620 
ureteral,  621 
uric  acid,  619 
Strangulation  of  bowel,  859 
etiolog}',  859 


INDEX. 


997 


Strangulation    of   bowel,    treatment, 

861 
Strapping    the    chest,    technic,    428, 

505 
Streptococci  as  cause  of  peritonitis, 

932 
Streptothricosis,  puhiionary,  494 
etiology,  494 
pathology,  495 
symptoms,  495 
treatment,  495 
Stricture    of    esophagus,    681.      See 

Esophagus. 
Strophanthin,  283 
Strophanthus,  282 

indications  for,  282 
Struma,   118 

Strychnin  as  a  cardiac  drug,  286 
Subacid  gastritis,  762 
treatment,  774,  778 
Subacute  bronchitis,  326.   See  Bron- 
chitis, 
general  peritonitis,  935 
Sublingual  ulcer,  671 
Succussion  splash,  532 
Sviffocative  pulmonary  edema,  476. 

See  Edema,  Pulmonary. 
Sugar  in  myocarditis,  234 
Sumrrter  diarrhea,  841 
Suppression     of    urine,     561.      See 

Anuria. 
Suppurative  gastritis,  acute,  757 

nephritis,  626 
Swedish   movements    in    heart    dis- 
ease, 296 
Syndrome,  Frohlich's,  160 

Stokes-Adams,  217 
Syphilis,   cerebrospinal,    gastric 
crises  in,  826 
complicating   pulmonary   tubercu- 
losis, 469 
iTiOuth  lesions  in,  666 
of  intestines,  872,  873 
of  live'-.  912.     See  Liver, 
of  stomach,  780.     See  Stomach, 
pulmonary,  489 

as  gummata,  489,  491 
patholog^^  489,  490 
symptoms,  491 
treatment,  492 
Syphilitic  affections  of  mouth,  666 

phthisis,  492 
Systemic  diseases  as  related  to  dis- 
eases of  the  mouth,  643 
Systoles,   premature,   208,   243 
in  arteriosclerosis,  270 

Tabloid,  Bland,  236 
Tachycardia,  paroxysmal,  209 
diagnosis,  209 


Tachycardia,  paroxysmal,  prognosis, 
209 
treatment,  210 
"Taking  the  cure,"  412,  413 
Teeth,  abscess  of,  in  heart  disturb- 
ances, 215 

and  tuberculosis,  646 

infections,  as  cause  of  disease,  644 
Tent,  window,  410 
Terminal   hypoadrenia,  11 

etiology,  11 

pathology,  11 

symptoms,  78 

treatment,  79 
Test,   Binet-Simon,  139 

coin,  532 

complement   fixation,   in   tubercu- 
losis, 375 

Edestin,  IZZ 

Esbach,  571 

for  albuminuria,  570,  571 

for  creatinin  in  blood,  610 

for  urea  in  blood,  608 

for  uric  acid  in  blood,  606 

Glenard's,  865 

Gluzinski,  692,  IZZ 

Heller's  blood,  567,  571 

indican,  561 

inoculation,    for    tubercle    bacilli, 
379 

Jaffe's,  551 

murexid,  550 

nephritic  test  diet,  605 

phenolsulphonephthalein,  604 

protein  sensitization,  352,  353 

renal  function,  604 

Schiff's,  550 

Von  Pirquet's,  374 

Weyl's,  551 
Testicles,  disorders  of,  184 

internal  secretion  of,   184 

transplantation  of,  188 
Testicular  insufficiency,  186 
etiology,  187 
symptoms,  186 
treatment,  187 

overactivit)^,  190 
symptoms,  190 
treatment,  191 
Tests,  protein  sensitization,  352,  353 
Tetany,  130,  132,  133 

etiology,  132 

postoperative,  129 
symptoms,  129 
treatment.  131 

symptoms,   132 

treatment,   133 
Thoracentesis,  514,  597 

dangers,  521 

indications,  516 


998 


INDEX. 


Thoracentesis,  technic,  517,  597 
Thoracic  aneurysm,  259,  261 
Thorium-X,  Zl 
Throat,  epidemic  sore,  665 
etiology,  665 
treatment,  665 
Thrush,  658 
etiolog}^  658 
symptoms,  658 
treatment,  658 
Thymectomy,  144 
•  effect  of,  134 
Thymic  asthm.a,  140,  142 
treatment,  143 
death,  140,  142 
etiology,  142 
Thymus  gland,  and  idiocy,  135,  136 
diseases  of,  133 
effect  of  removal,  134 
function  of,  135 
histolog\^  of,  133 
h3'perplasia  of,  140 
etiology,  140 
treatment,  143 
X-ray,  143 
in  backward  children,  138 
in  exophthalmic  goiter,  112,  115 
insufficiency  of,   135.     See   Hypo- 
thymia. 
Thyroid,  absorption  of  iodin,  95 
gland,  administration  of  dried,  101 
anatomy  of,  92 
connection  with  adrenals,  71 
diseases  of,  92 
nervous   stimulation  of,   95 
physiology  of,  92-98 
result  of  excision  of,  93 
in  exophthalmic  goiter,  117 
grafting,  105 
insufficiency,    98.      See    Hypothy- 

roidia. 
overactivity,  109.     See  Hyperthy- 
roidia     and     Exophthalmic 
Goiter, 
secretion,  excessive,  94 
germicidal  action  of,  97 
influence  of,  on  metabolism,  95 
Thyroidase,  98 

Thvroidectomv,  results  of,  93 
Thyroiditis,  107 
acute,  107 
complications  of,  107 
etiology,  107 
sjnnptoms,  107 
treatment,  108 
chronic,  108 
etiology,  108 
treatment,  109 
parasitic  form,  108 
Tinkle,  metallic,  532 


Tongue,  carcinoma  of,  671 

enlargement  of,  672.     See  Macro- 

glossia. 
diseases  of,  668-672 
geographical,  669 
treatment,  670 
gumma  of,  670 
treatment,  670 
inflammation    of,    668,    669.      See 

Glossitis, 
tuberculosis  of,  670 

treatment,  670 
tumors  of,  671 

treatment,  671 
ulcer  of,  671 

white,  670.     See  Leucoplakia. 
Tonsillectomy,  in  gastric  ulcer,  696 

in  Hodgkin's  disease,  47 
Tonsils  as  source  of  systemic  dis- 
eases, 645 
Toxic  dyspnea  in  nephritis,  603 
treatment,  616 
gastritis,  753.     See  Gastritis, 
goiter,  119,  122 
T.  R.,  431 
Transfusion  of  blood  in  pernicious 

anemia,  23 
Transplantation  of  ovaries,  181 

of  testicles,  188 
Transudate  vs.  exudate,  differentia- 
tion of  pleural,  500 
Trench  jaundice,  883 
Triangle,  Grocco's,  513 
Tricuspid  regurgitation,  254 
etiology,  254 
prognosis,  248 
symptoms,  254 
stenosis,  255 
prognosis,  248 
with  mitral  stenosis,  255 
Tubal  pregnancy  differentiated  from 

pelvic  peritonitis,  956 
Tubercle  bacilli,  378 

inoculation  test  for,  379 
staining  of,  378 
Tubercles,  371 

calcification  of,  371,  372 
caseation  of,  371,  372 
sclerosis  of,  371,  372 
Tuberculin,  430 
dosage,  432 

in    gastric   tuberculosis,    795 
in  Hodgkin's  disease,  46 
in  kidney  tuberculosis,  638 
in  leukemia,  40 
in  phthisis,  430 
contraindication  to,  433 
dosage,  432 
Tuberculosis,  bovine,  402,  403 
intestinal,  446,  871 


INDEX. 


999 


Tuberculosis, intestinal, frequency  ,446 
in  infants,  871 

primary,  871 

secondary,  872 

symptoms,  871 

treatment,  872 
symptoms,  446 
treatment,  446 
of  kidney,  633.     See  Kidney, 
of  liver,  913 

of  stomach,  789.     See  Stomach, 
of  tongue,  670 
pulmonar}^  371 

acute  g-eneral  miliary,  400 
alcohol  in,  429 

objections  to,  429,  430 
ammonium  chloride  in,  449 
anemia  in,  382,  459 

treatment,  459 
anorexia  in,  442 
arsenic  in,  459 
as  a  cause  of  nephritis,  590 
associated  diseases,  468 
ai'tificial  pneumothorax   in,  423 

contraindications,  424 

dangers,  424 

for  hemoptysis,  455 

indications,  424 

results,  425 

technic,  427 
auscultation,  394 
bathing,  422,  423,  456,  457 
blistering  in,  461 
blood-pressure,  382 
breath  sounds,  394 

types,  395 
bronchitis  in,  447 
bubbling  rales  in,  397 
calcification  in,  371,  372 
cardiac     disease     complicating, 
468,  469 

palpitation  in.  382 
caseation  in,  371,  372 
cavity  formation  in,  372,  397 
chest,      diminished      expansion, 
385,  386 

inspection,  383,  384 

mensuration,  388 

pain,  449,  450 

strappino-,  428,  505 
chronic  ulcerative,  400,  401 
class  method  of  instruction,  435 
climate   in   treating,   408 
clubbed  fingers,  384 
cold  liath,  422 
cold  sponges,  422,  423.  457 
complement     fixation    test     for 

diagnosing,  375 
complications,  460 
constipation,  444 


Tuberculosis,    pulmonary,    constipa- 
tion, treatment,  446 
cough,  2m,  446 

treatment,  446 
creosote  in,  448 

indications,  448 

method  of  administering,  448 
curved  finger  nails  in,  384 
"danger  zone,"  397 
determination     of     degree     of 
activity,  401 

of  improvement,  401 
diabetes  complicating,  470 

treatment,  470 
diagnosis,  383 
diarrhea,  445 

etiology,  445 

treatment,  445 
diet,  416 

calories  needed,  417 

in  children,  422 

milk  and  egg,  417 
dispensary  treatment,  433 

cases  suitable,  434 

functions,  441 
eggs,    method    of    taking,    418, 

419 
exercise,  412 

contraindications,  414 

deep  breathing,  416 

walking,  414 

working,  415 
expectoration,  ZT7 

disposal  of,  404 
facial  characteristics,  383 
fever,  379,  456 

following  exercise,  380 

menstrual,  380 

premenstrual,  380 

treatment,  456 
fistula-in-ano  complicating,  468 

significance,  468 

treatment,  468 
fibrous    tissue    formation,    371, 

372 
fresh  air,  409 
gastro-intestinal       disturbances, 

441 
hemoptysis.  380,  451 

causes,  451 

treatment,  452.  453 
hemorrhages,  380,  381 
hoarseness,  380 
home  treatment,  407,  408 

visitation,  437 
hospital  treatment.  406,  407,  408 
hydrotheranv,  422,  456 
immunity,  373 
inspection,  Z%Z 


1000 


liNDEX. 


Tuberculosis,   pulmonary,   intestinal 
tuberculosis  complicating,  446 
iron  in,  459 

Kronig's  isthmus,  392,  393 
location  of  first  foci  in,  371 
loss  of  appetite  in,  442 

of  weight,  381 
method  of  dissemination,  404 
miliary,  400 

milk  and  eggs,  417,  418.  419 
mixed    infections    complicating, 
463 

treatment,  464 
mode  of  onset,  Zll 
moist  rales,  397 
nephritis  complicating,  464 

treatment,  465 
nitrites  in,  453 
oil  inunctions,  451 
opium  in.  449,  453 
pain  in,  449 

treatment.  450 
palpation,  383 
pathology,  371 
patient's  history,  ZTd 
pectoriloqu}^  398 
percussion,  390 

technic,  391 
physical  signs,  383 
pityriasis  versicolor,  384 
pleural  effusion  in,  460 

treatment,  460 
pleuritis,  502,  503,  507 
pneumothorax  complicating, 
462,  533 

cause.  462 

treatment,  462 
pregnancy  complicating,  471 

treatment,  471 
prevention,  402 

public  education  in,  405 
pulse  rate,  382 
rales,  396 

method  of  eliciting,  397 

significance,  397 
rest,  412 
sanatorium  treatment,  406 

advantages,  407 

disadvantages,  407 
sibilant  rales.  397 
skodaic  resonance,  393 
smoking,  447 
sonorous  rales,  397 
sources  of  infection,  402 
sponging,  422,  423,  457 
sputum,  378 

stereoscopic   examination.  398 
symptoms,  Zll 

cardiovascular,  382 

gastro-intestinal,  381,  441 


Tuberculosis,  pulmonary,  symptoms, 
nervous,  383.  449 
syphilis  associated  with,  469 

treatment,  469 
"taking  the  cure,"  412,  413 
teeth  and,  646 
treatment,  399,  406 
climatic,  408 
dispensary,  433 
fresh  air,  409 
general,  406 
home,  407,  408 
medicinal,  428' 
of  special  symptoms,  441 
prophylactic,  402 
specific,  428 
tuberculin.  430 
tuberculin  treatment,  430 
contraindication,  433 
dosage,  432 
tuberculous     laryngitis     compli- 
cating. 467 
treatment,  467 
tj^pes,  400 
vaccines  in,  464 
vicarious  menstruation,  381 
vocal  resonance,  398 
vomiting,  442 
causes,  442.  443 
treatment,  443 
von  Pirquet's  test,  374 
X-ray,  398 

interpretation,  399 
value,  398.  399 
Tuberculous    adenitis   differentiated 
from  Hodgkin's  disease,  45 
infection  without  disease,  374 
larjmgitis,  467 

treatment,  467 
peritonitis,  946 

treatment,  951 
pleuris}',  460 

treatment,  460 
pneumonia,  400 
resistance,  372 

ulcer  of  stomach  and  duodenum, 
789 
Tubular  breathine-.  396 
Tubulonephritis,   578,  579.   580 
Tufnel's  treatment  of  aneurysm,  265 
Tumors,  of  adrenals,  90 
of  kidnev.  639 
of  liver,  "913 
of  pleura,  526 
of  tongue,  671 
peritoneal,    963.      See    Peritoneal 

Neoplasms, 
pineal,  171 
pituitary,  151 
pulmonary,  495 


INDEX. 


lOfJl 


Ulcer  of  esophagus,  675 
etiology,  675 
symptoms,  676 
treatment,  676 
of  stomach  and  duodenum,  684 
acute  dilatation  of  stomach   in, 

721 
age  incidence  of,  687 
breathing  exercises  in,  696 
carcinoma    following,   688,   691, 

m 

care  of  body  in,  696 

of  mouth,  695 
complications  of,  688,  691 

treatment,  718 
diagnosis,  692 
diet  in,  703 

daily  schedule,  704-709 

essentials   of,   703 

in  follow-up  treatment,  712 

Lenhartz,  703 

Smithie's,  for  emaciation,  716 

von  Leube,  703 
drugs  in,  700 
duodenal   feeding  in,  714 

objections  to,  717 

technic,  714 
duration  of,  688 
Einhorn's  duodenal  feeding  in, 
714 

objections  to,  717 

technic,  714 
etiolog3^  684 
frequency  of,  686 
general  hygiene  in  treatment  of, 

695 
hemorrhage  from,  692 

treatment,  698,  721 
hour-glass  contraction  in,  692 
hypersecretion  in,  692 

treatment,  719 
local   applications   of   heat   and 

cold  in,  697 
location  of  ulcers  in,  687 
mortality,  688 
number  of  ulcers  in,  687 
nutritive  enemas  in,  699 
perigastric  abscess   from,  692 
prognosis,  687 

pyloric  obstruction   from,  692 
results  of  operation  for,  689 
sex  incidence  of,  687 
size  of  ulcers  in,  687 
tonsillectomy  in,  696 
treatment,  693,  700 
alkali,  701,  702 
daily  schedule  in,  705-710 
essentials  of,  693 
follow-up.  710 
of   complications,   718 


Ulcer    of    stomach    and    duoikiumi, 
treatment    of    hemorrhage, 
698,  721 
of  hemorrhoids,  699 
of  hypersecretion,  719 
of  pain,  718 
of  perforation,  723 
of  relapsing  cases.  714 
of  special  symptoms,  718 
of  thirst,  698 
of  vomiting,  720 
Sippy's,  701 
tuberculous.  789 
of  tongue,  671 
sublingual,  671 
Ulcerative  colitis,  848 
enteritis,  839 

stomatitis,  659.     See  Stomatitis. 
Urea,  547 
amount  of,  547 
estimation  of,  549 
formation  of,  548 
in  blood,  estimation  of,  608 
Uremia,  582,  604 
treatment,  617 
Ureteral  stones,  621 
Uric  acid,  550 

in  blood,  estimation  of,  606 
origin  of,  550 
stones,  619 
tests  for,  550 
Urinary  phosphates,  552 
amount  of,  552 
origin  of,  552 
tests  for,  552 
salts,  552 
solids,  547 
estimation  of,  547 
Urine,  anomalies  of  secretion  of,  561 
albuminuria,  569 
anuria,  561 
casts,  572 
chyluria,  568 
cyiindroids,  574 
hematuria,  563 
hemoglobinuria,  565 
characteristics  of   normal,   546 
excretion  of,  545 

in    acute    parenchymatous    neph- 
ritis, 581       " 
in    chronic    interstitial    nephritis. 

602 
in  chronic  parenchymatous  neph- 
ritis, 591 
retention    of,    differentiated    from 

suppression.  562 
suppression  of,  561.     See  Anuria. 

Vaccines    in    acute    infectious    gas- 
tritis, 756 


1002 


INDEX. 


Vaccines  in  asthmatics,  355 
in  bronchiectasis,  345 
in  chronic  bronchitis,  336 
in    chronic    non-tuberculoi       pul- 
monary infections,  474 
in  endocarditis,  241 
in  Hodgkin's  disease,  47 
in  puhnonary  tuberculosis,  464 
in     treating-     diseases     of     lungs, 
bronchi,  and  pleura,  534 
Valves,  rupture  of  heart,  254 
Valvular  disease  of  heart,  242 
and  muscular  disease,  243 
congenital,  249 
clinical  patholog^^  242 
effects  of,  243 
general  treatment,  246 
pathologic  phvsiolog^^  247 
patholog}^  243,  244,  "245 
prognosis.  248,  249 

conditions  influencing,  243 
pulmonar}',  255 
A'enesection  in  aneurv^sm,  265 
in  Dernicious  anemia,  24 
technic,  588 
Venous  hum,  in  anemia,  6 

in  chlorosis,  10 
Vesicular  emphysema,   diffuse,   361, 
_    362        ■ 
etiology',  362 
pathology,  363 
S3miptoms,  364 
treatment,  367 
stomatitis,    656.      See    Stomatitis, 
Aphthous. 
Vicarious  menstruation   in  pulmon- 
ary tuberculosis,  381 
Vincent's  angina,  659.     See  Stoma- 
titis, Ulcerative. 
Visceral  crises,  826 
peritoneum,  928 
Visceroptosis,    862.      See    also    En- 

teroptosis. 
Vocal  resonance  in  pulmonary  tub- 
erculosis, 398 
Volvulus,  859 

Vomiting   in   acute  gastritis,   treat- 
ment of,  752 
in    gastric    carcinoma,    treatment 
of,  729,  730 


Vomiting  in  pulmonary  tuberculosis, 
442,  443 
in    ulcer    of    stomach    and    duod- 
enum, 720 
von  Jaksch's  splenic  anemia,  48 
^■on  Leube's  diet,  703 
von  Pirquet's  test,  374 

Walking  exercise  in  pulmonarj'  tub- 
erculosis, 414 

Waxy  casts,  574,  575 

Wenzel's    classification    of    cretins, 
104 

Wevl's  test,  551 

White  kidney.  591 
line,  Sergent's,  80 
nneumonia,  489 
tongue,  670.     See  Leucoplakia. 

\\'indow  tent,  410 

Wiring  aneurysms,  266 

Woillez's  disease,  474 

^\'olff-Junghan  reaction,  733 

Working     exercise     in     pulmonary 
tuberculosis,  415 

Xerostoma,  672 
etiolog^^  672 
treatment,  672 
X-rav   diagnosis,   of   bronchiectasis, 
343 
of  pulmonary  tuberculosis,  398, 

399_ 
of  syphilis  of  stomach,  783 
in  er3'themia,  62 
in   exophthalmic   goiter.    115 
in  gastric  carcinoma.  745 
in  Hodgkin's  disease,  46 
in  leukemia,  33 
in  pernicious  anemia,  27 
in  splenic  anemia,  50 
in  thymic  h^'perplasia,  143 

Yellow  atrophy  of  liver,  acute,  908. 
See  Liver. 

Zone,  danger,  in  pulmonary  tuber- 
culosis, 397 
of  peritoneum,  929 


inr«    »         fH^C^?^ 


